Global and regional estimates
of violence against women:
prevalence and health effects of
intimate partner violence and
non-partner sexual violence
II
Global and regional estimates of violence against women
WHO Library Cataloguing-in-Publication Data:
Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and nonpartner sexual violence.
1.Violence. 2.Spouse abuse. 3.Battered women – statistics and numerical data. 4.Sex offenses. 5.Women’s health services. I.World
Health Organization.
ISBN 978 92 4 156462 5
(NLM classification: HV 6625)
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Prevalence and health effects of intimate partner violence and non-partner sexual violence
Contents
AcknowledgementsV
AbbreviationsVI
Preface1
Executive summary
2
Introduction4
Definitions and conceptual framework
5
Health outcomes and causal pathways
5
Section 1: Methodology
9
Measurement of exposure to intimate partner violence and non-partner sexual violence
9
Definitions of WHO regions
9
Prevalence estimates of intimate partner violence
9
Compilation of evidence on the prevalence of intimate partner violence
10
Compilation of evidence on the prevalence of non-partner sexual violence
11
Methods to obtain regional and global prevalence estimates of intimate partner violence
and non-partner sexual violence
13
Section 2: Results – lifetime prevalence estimates
16
Global and regional prevalence estimates of intimate partner violence
16
Global and regional prevalence estimates of non-partner sexual violence
18
Combined estimates of the prevalence of intimate partner violence and non-partner violence
20
Section 3: Results – the health effects of intimate partner violence and non-partner sexual violence
21
Health effects of exposure to intimate partner violence
21
HIV and other sexually transmitted infections
22
Induced abortion
23
Low birth weight and prematurity
23
Harmful alcohol use
24
Depression and suicide
24
Non-fatal injuries
25
Fatal injuries (intimate partner homicides)
26
III
IV
Global and regional estimates of violence against women
Health effects of exposure to non-partner sexual violence
27
Depression and anxiety
27
Alcohol use disorders
28
Section 4: Summary and conclusions
31
Summary of findings
31
Limitations of the review
32
Implications of the findings
33
Research gaps
33
Conclusions35
References37
Appendix 1: Countries included by WHO region and age group
44
Appendix 2: Prevalence estimates of violence against women by Global Burden of Disease regions
47
Intimate partner violence
47
Non-partner sexual violence
48
Appendix 3: Regression models for calculating regional estimates of intimate partner violence
and non-partner sexual violence
49
Regression function to estimate regional levels of intimate partner violence
49
Regression function to estimate age-group-specific regional levels of intimate partner violence
49
Regression function to estimate regional levels for non-partner sexual violence
50
Prevalence and health effects of intimate partner violence and non-partner sexual violence
Acknowledgements
This report was written by Claudia García-Moreno and Christina Pallitto of the Department of Reproductive
Health and Research (RHR) of the World Health Organization (WHO), Karen Devries, Heidi Stöckl and Charlotte
Watts of the London School of Hygiene and Tropical Medicine (LSHTM), and Naeemah Abrahams from the
South African Medical Research Council (SAMRC). Max Petzold from the University of Gothenburg provided
statistical support to all of the analyses.
The report is based on work done by the Expert Group on intimate partner violence, non- partner sexual
violence and child sexual abuse for the Global Burden of Disease Study 2010, which was chaired by Charlotte
Watts, LSHTM and Claudia García-Moreno, WHO. The systematic reviews of evidence on intimate partner
violence were overseen by Karen Devries, LSHTM, and Christina Pallitto, WHO. The reviews of
non-partner sexual violence were overseen by Naeemah Abrahams, SAMRC. Loraine Bacchus, Jennifer Child,
Gail Falder, Amber Hill, Joelle Mak and Jennifer McCleary-Sills, also contributed to the systematic reviews.
Special thanks go to Gretchen Stevens and Colin Mathers of WHO’s Department of Health Statistics and
Information Systems, for their careful review of the data and methods for the estimations.
Thanks also to Michael Mbizvo and Marleen Temmerman, previous and current Director RHR for their support
and inputs and to Catherine Hamill and Janette Petitpierre of RHR for the design and layout of the report.
The report was produced by RHR, WHO and edited by Penny Howes.
V
VI
Global and regional estimates of violence against women
Abbreviations
AIDS
acquired immunodeficiency syndrome
aOR
adjusted odds ratio
CDC
Centers for Disease Control and Prevention
CES-D
Centre for Epidemiological Studies Depression Scale
CI
confidence interval
CINAHL
Cumulative Index to Nursing and Allied Health Literature
CTS
Conflict Tactics Scale
DHS
Demographic and Health Survey
DSM-IV
Diagnostic and statistical manual of mental disorders, fourth edition
GBD
Global Burden of Disease
GENACIS
Gender, alcohol and culture: an international study
HIV
human immunodeficiency virus
IMEMR
Index Medicus for the WHO Eastern Mediterranean Region
IMSEAR
Index Medicus for the WHO South-East Asia Region
IVAWS
International Violence Against Women Survey
LSHTM
London School of Hygiene and Tropical Medicine
OR
odds ratio
PTSD
post-traumatic stress disorder
RHS
reproductive health survey (CDC)
SAMRC
South African Medical Research Council
STI
sexually transmitted infection
USA
United States of America
WHO
World Health Organization
WPRIM
Western Pacific Region Index Medicus
Prevalence and health effects of intimate partner violence and non-partner sexual violence
Preface
Violence against women is not a new phenomenon, nor are its consequences to women’s physical, mental
and reproductive health. What is new is the growing recognition that acts of violence against women are not
isolated events but rather form a pattern of behaviour that violates the rights of women and girls, limits their
participation in society, and damages their health and well-being. When studied systematically, as was done
with this report, it becomes clear that violence against women is a global public health problem that affects
approximately one third of women globally.
By compiling and analysing all available data from studies designed to capture women’s experiences of
different forms of violence, this report provides the first such summary of the violent life events that many
women experience. It documents not only how widespread this problem is, but also how deeply women’s
health is affected when they experience violence.
This report marks a big advance for women’s health and rights. It adds to the momentum of the 57th
session of the Commission on the Status of Women, which emphasized the need to address the root causes
of violence against women and to strengthen multisectoral responses for women who have experienced
violence. It also contributes to advocacy efforts such as the United Nations Secretary General’s campaign
UNiTE to end violence against women.
Action is clearly needed, and the health sector has an especially important role to play, considering the
serious health risks faced by women and their families. WHO’s new clinical and policy guidelines on the
health sector response to violence against women provide specific evidence-based guidance that can help
to strengthen the way health-care providers respond to women who have experienced violence. They also
stress the importance of incorporating issues of violence into clinical training curricula, strengthening health
systems to support women through direct services and multisectoral responses, identifying key entry points,
such as sexual and reproductive health services and mental health services for addressing violence, and
scaling up appropriate post-rape care responses.
No public health response is complete without prevention. Violence against women can and should be
prevented. Promising programmes exist and many hinge on promoting gender equality so that the full
potential of the world’s women and girls can be realized. Let this report serve as a unified call to action for
those working for a world without violence against women.
Flavia Bustreo
Assistant Director General
Family, Women and Children’s Health
World Health Organization
Peter Piot
Director and Professor of Global Health,
London School of Hygiene & Tropical Medicine
Professor Salim S. Abdool Karim
President: South African Medical
Research Council
Oleg Chestnov
Assistant Director General
Noncommunicable Diseases and Mental Health
World Health Organization
1
2
Global and regional estimates of violence against women
Executive summary
“There is one universal truth, applicable to all
countries, cultures and communities: violence
against women is never acceptable, never
excusable, never tolerable.”
• most of this violence is intimate partner
violence. Worldwide, almost one third (30%) of
all women who have been in a relationship have
experienced physical and/or sexual violence by
United Nations Secretary-General, Ban Ki-Moon
their intimate partner. In some regions, 38%
(2008)1
of women have experienced intimate partner
Violence against women is a significant public
health problem, as well as a fundamental violation
of women’s human rights.
This report, developed by the World Health
violence;
• globally, as many as 38% of all murders of
women are committed by intimate partners;
• women who have been physically or sexually
Organization, the London School of Hygiene
abused by their partners report higher rates
and Tropical Medicine and the South African
of a number of important health problems. For
Medical Research Council presents the first global
example, they are 16% more likely to have a
systematic review and synthesis of the body of
low-birth-weight baby. They are more than
scientific data on the prevalence of two forms
twice as likely to have an abortion, almost twice
of violence against women — violence by an
as likely to experience depression, and, in some
intimate partner (intimate partner violence) and
regions, are 1.5 times more likely to acquire
sexual violence by someone other than a partner
HIV, as compared to women who have not
(non-partner sexual violence). It shows, for the first
experienced partner violence;
time, aggregated global and regional prevalence
• globally, 7% of women have been sexually
estimates of these two forms of violence,
assaulted by someone other than a partner.
generated using population data from all over the
There are fewer data available on the health
world that have been compiled in a systematic way.
effects of non-partner sexual violence. However,
The report also details the effects of violence on
the evidence that does exist reveals that women
women’s physical, sexual and reproductive, and
who have experienced this form of violence
mental health.
are 2.3 times more likely to have alcohol
The findings are striking:
use disorders and 2.6 times more likely to
• overall, 35% of women worldwide have
experience depression or anxiety.
experienced either physical and/or sexual
There is a clear need to scale up efforts across
intimate partner violence or non-partner sexual
a range of sectors, both to prevent violence
violence. While there are many other forms of
from happening in the first place and to provide
violence that women may be exposed to, this
necessary services for women experiencing
already represents a large proportion of the
violence.
world’s women;
1. Secretary-General says violence against women never
acceptable, never excusable, never tolerable, as he launches
global campaign on issue. New York, United Nations Department of Public Information, News and Media Division, 2008 (SG/
SM/11437 WOM/1665).
Prevalence and health effects of intimate partner violence and non-partner sexual violence
The variation in the prevalence of violence seen
and emergency services. Comprehensive post-
within and between communities, countries and
rape care services need to be made available and
regions, highlights that violence is not inevitable,
accessible at a much larger scale than is currently
and that it can be prevented. Promising prevention
provided.
programmes exist, and need to be tested and
scaled up.2 There is growing evidence about what
factors explain the global variation documented.
This evidence highlights the need to address the
economic and sociocultural factors that foster
a culture of violence against women. This also
includes the importance of challenging social
norms that support male authority and control
over women and sanction or condone violence
against women; reducing levels of childhood
exposures to violence; reforming discriminatory
family law; strengthening women’s economic and
legal rights; and eliminating gender inequalities in
access to formal wage employment and secondary
education.
Services also need to be provided for those who
have experienced violence. The health sector
must play a greater role in responding to intimate
partner violence and sexual violence against
women. WHO’s new clinical and policy guidelines
on the health-sector response to violence against
women emphasize the urgent need to integrate
issues related to violence into clinical training.
It is important that all health-care providers
understand the relationship between exposure to
violence and women’s ill health, and are able to
respond appropriately. One key aspect is to identify
opportunities to provide support and link women
with other services they need – for example,
when women seek sexual and reproductive health
services (e.g. antenatal care, family planning,
post-abortion care) or HIV testing, mental health
2. Preventing intimate partner violence and sexual violence
against women. Taking action and generating evidence. Geneva,
World Health Organization, 2010.
The report shows that violence against women is
pervasive globally. The findings send a powerful
message that violence against women is not a
small problem that only occurs in some pockets of
society, but rather is a global public health problem
of epidemic proportions, requiring urgent action.
It is time for the world to take action: a life free
of violence is a basic human right, one that every
woman, man and child deserves.
3
4
Global and regional estimates of violence against women
Introduction
There is growing recognition that violence against
and its health effects. This is, in part, a result of
women has a large public health impact, in addition
a growing consensus on how best to measure
to being a gross violation of women’s human rights
women’s exposure to intimate partner (and other
(1). This recognition is the result of international
forms of) violence through household surveys,
commitments to document the magnitude of the
while also taking precautions to put women’s
problem and its consequences and the ever-
safety first and to ensure that respondents
expanding evidence base on the prevalence and
requesting assistance can be referred to services if
consequences of this violence. The United Nations
needed (3). As well as specialized surveys, national
Secretary-General, Ban Ki-Moon, has issued a
governments are increasingly incorporating
global call to action to end violence against women,
questions on women’s exposure to partner violence
by launching the UNiTE to End Violence against
into their national health surveys, including, for
Women campaign. Most recently, the agreed
example, in the Demographic and Health Surveys
conclusions of the 57th session of the Commission
(DHSs) (4) and the Centers for Disease Control
on the Status of Women (2) emphasize the
and Prevention (CDC) reproductive health surveys
importance both of addressing structural and
(RHSs) (5).
underlying causes and risk factors in order to
prevent violence against women and girls, and of
strengthening multisectoral services, programmes
and responses for victims and survivors. The
agreed conclusions also call for continued
multidisciplinary research and analysis on the
causes of, and cost and risk factors for, violence
against women and girls, in order to inform laws,
policies and strategies and support awarenessraising efforts.
The term “violence against women” encompasses
many forms of violence, including violence by an
intimate partner (intimate partner violence) and
rape/sexual assault and other forms of sexual
violence perpetrated by someone other than a
partner (non-partner sexual violence), as well as
female genital mutilation, honour killings and the
trafficking of women.
This report focuses on two forms of violence
against women: physical and/or sexual intimate
partner violence and non-partner sexual violence.
Over the past decade, there has been a rapid
growth in the body of research evidence available
on the prevalence of intimate partner violence
Similarly, for sexual violence by perpetrators
other than a partner (i.e., friends, acquaintances,
strangers, other family members), there is a
growing body of research evidence on levels of
such violence, although this is much more limited
than for intimate partner violence. There is growing
consensus on how best to document exposure to
sexual violence, although, in practice, definitions
may vary between studies, and not all forms of
sexual violence are well documented.
This report presents the first global systematic
review and synthesis of the body of scientific data
measuring the population prevalence of intimate
partner violence against women, and non-partner
sexual violence against women. It presents, for
the first time, aggregated global and regional
prevalence estimates of these two forms of
violence, generated using population data from all
over the world, compiled in a systematic way.
The report is divided into three sections, with a
fourth summary and conclusions section. Section 1
describes the methods used for calculating the
global and regional prevalence estimates of
intimate partner violence and non-partner sexual
Prevalence and health effects of intimate partner violence and non-partner sexual violence
violence,3 and section 2 presents the global and
regional prevalence estimates for each form of
violence. Section 3 summarizes evidence on the
magnitude of a range of health effects associated
with exposure to either form of violence. These
analyses are based on systematic reviews and
data pooled across surveys, analysed using metaanalysis where possible. This evidence shows that
women experiencing intimate partner violence
are significantly more likely to experience serious
health problems than women who have not
experienced such violence. The health effects of
non-partner sexual violence are also presented,
although fewer outcomes are included in this
section because of the relative lack of research in
this area.
Health outcomes and causal
pathways
While there has been an important growth during
the past decade in the number of population-based
studies globally that are starting to document the
prevalence/magnitude of different forms of violence
against women, there has been less research on
the health effects of exposures to different forms
of violence (6). However, what this literature does
highlight is the extreme breadth in potential health
effects – encompassing physical, sexual and
reproductive, and mental health, with potentially
large impacts on levels of women’s morbidity
and mortality. This evidence comes from a few
rigorous, prospective and carefully controlled
clinical and epidemiological research studies, and,
This evidence shows that both intimate partner
more commonly, from assessments of association
violence and non-partner sexual violence are
using population-based cross-sectional data. As
widespread and that they have important effects
described in more detail below, although the field’s
on women’s physical, sexual and reproductive, and
reliance on cross-sectional data is a limitation,
mental health. In combination, these findings send
the studies used are often large, representative,
a powerful message that violence against women
population-based surveys that have been replicated
is not a small problem that only occurs in some
in multiple settings, with strong consistency of
pockets of society, but rather is a global public
findings across studies.
health problem of epidemic proportions, requiring
urgent action.
The likely causal pathways between different
forms of exposure to violence and different health
Definitions and conceptual
framework
outcomes are starting to be documented and
Table 1 summarizes the working definitions for
behavioural and other factors influencing the
each form of violence used in this review.
likelihood of disease/ill-health outcomes.
understood better. These pathways are often
complex, with context-specific, physiological,
There is a broad range of health effects. Figure 1
shows the hypothesized pathways through which
intimate partner violence leads to different forms
of morbidity and mortality. These include the direct
3. The age of 15 years is set as the lower age limit for partner
violence and non-partner sexual violence, so while we refer to
“violence against women” throughout the report, we recognize
that violence experienced by girls between the ages of 15 and
18 years is also considered child maltreatment.
pathway of violence resulting in injury and death,
and the other direct and indirect pathways for
multiple health problems for women, as well as
maternal and perinatal health outcomes.
5
6
Global and regional estimates of violence against women
Table 1. Working definitions of forms of exposure to violence used in this review
Term
Definition for this review
Intimate partner
violencea
Self-reported experience of one or more acts of physical and/or sexual violence by a
current or former partner since the age of 15 years.b
∙
Physical violence is defined as: being slapped or having something thrown at you
that could hurt you, being pushed or shoved, being hit with a fist or something
else that could hurt, being kicked, dragged or beaten up, being choked or burnt
on purpose, and/or being threatened with, or actually, having a gun, knife or other
weapon used on you.
∙
Sexual violence is defined as: being physically forced to have sexual intercourse
when you did not want to, having sexual intercourse because you were afraid of
what your partner might do, and/or being forced to do something sexual that you
found humiliating or degrading.c
Severe intimate
partner violence
Is defined on the basis of the severity of the acts of physical violence: being beaten
up, choked or burnt on purpose, and/or being threatened or having a weapon used
against you is considered severe. Any sexual violence is also considered severe.
Current intimate
partner violence
Self-reported experience of partner violence in the past year.
Prior intimate
partner violence
Self-reported experience of partner violence before the past year.
Non-partner sexual
violence
When aged 15 years or over,b experience of being forced to perform any sexual act
that you did not want to by someone other than your husband/partner.
a
The definition of intimate partner varies between settings and includes formal partnerships, such as marriage, as well
as informal partnerships, including dating relationships and unmarried sexual relationships. In some settings, intimate
partners tend to be married, while in others more informal partnerships are more common.
b
The age of 15 years is set as the lower age range for partner violence and non-partner sexual violence. Intimate
partner violence has only been measured for women who have reported being in a partnership, as they are the
“at-risk” group. Therefore, for women between the ages of 15 and 18 years, only those who have been in a partnership,
including dating relationships and marital relationships in settings where marriage occurs in this age group, could
potentially report intimate partner violence. Young women in the age group 15–18 years experiencing non-partner
sexual violence can also be considered, by some legal definitions, to have experienced child sexual abuse, as these are
not mutually exclusive categories.
c
The definition of humiliating and degrading may vary across studies, depending on the regional and cultural setting.
Prevalence and health effects of intimate partner violence and non-partner sexual violence
A more indirect pathway, mediated by stress
and part of the complex link between exposures to
responses, is documented in a body of research
violence and other health risk factors that mediate
that has expanded rapidly over the past two
negative health outcomes.
decades. This literature provides good evidence
about the underlying biological (physiological)
mechanisms of the association between exposures
to violence and different adverse health outcomes,
through complex and interconnected neural,
neuroendocrine and immune responses to acute
and chronic stress (7–9). For example, when
exposed to prolonged or acute stress, areas of the
brain such as the hippocampus, amygdala and
prefrontal cortex undergo structural changes that
have implications for mental health and cognitive
functioning, and can lead to mental disorders,
somatoform disorders or chronic illness, as well
as other physical conditions (10). In response to
stress, the immune system can be compromised,
exacerbating the spread of cancer and viral
infections. Sustained and acute elevated stress
levels have also been linked to cardiovascular
disease, hypertension, gastrointestinal disorders,
chronic pain, and the development of insulindependent diabetes (10). Stress during and around
the time of pregnancy has been linked with lowbirth-weight infants, as rising cortisol levels lead
to constriction of the blood vessels, limiting blood
flow to the uterus. Furthermore, the hypothalamic–
pituitary–adrenal response can trigger premature
labour and premature birth, through contractions of
the smooth muscle tissue in the uterus (11, 12).
In addition to the biological stress response,
there are behavioural and other risk factors that
also influence the link between intimate partner
violence and adverse health outcomes. Some
women try to manage the negative consequences
of abuse through the use of alcohol, prescription
medication, tobacco or other drugs (13, 14). Each
of these is an important risk factor for poor health,
An additional, less documented, but emerging
pathway relates to the psychological control
that defines many relationships in which partner
violence occurs. These controlling behaviours
relate to a series of ways in which male partners
might attempt to control and/or limit the behaviours
and social interactions of their female partners
(e.g., limiting social and family interactions,
insisting on knowing where she is at all times,
being suspicious of unfaithfulness, getting angry
if she speaks with another man, expecting
his permission for seeking health care). Such
controlling behaviour often co-occurs with physical
and sexual violence, and may be highly prevalent in
violent relationships. Emerging evidence suggests
that abusive partners who exhibit these behaviours
can limit women’s ability to control their sexual
and reproductive decision-making, their access
to health care, or their adherence to medications,
which can have adverse health effects.
As illustrated in Figure 1, the relationship between
exposures to violence and health effects is
complex. Intrinsic in many of these postulated
associations is the assumption that there are
intermediate pathways, such that violence might
increase the tendency to a particular risk behaviour
and that risk behaviour, in turn, increases the
likelihood of an adverse health outcome. The data
to date, however, are limited; they are mostly
cross-sectional and do not allow temporality or
causality to be determined. More and different
kinds of research, such as longitudinal studies,
inclusion of biomarkers to measure health
outcomes, and properly controlling for potentially
confounding variables affecting the associations
found, are needed to be able to describe these
pathways and associations more conclusively.
7
8
Global and regional estimates of violence against women
Figure 1. Pathways and health effects on intimate partner violence
INTIMATE PARTNER VIOLENCE
PHYSICAL TRAUMA
FEAR AND CONTROL
PSYCHOLOGICAL TRAUMA/
STRESS
MENTAL HEALTH
PROBLEMS
• PTSD
• anxiety
• depression
• eating disorders
• suicidality
INJURY
• musculoskeletal
• soft tissue
• genital trauma
• other
LIMITED SEXUAL AND
REPRODUCTIVE
CONTROL
• lack of contraception
• unsafe sex
HEALTH CARE
SEEKING
• lack of autonomy
• difficulties seeking
care and other
services
PERINATAL/MATERNAL
HEALTH
• low birth weight
• prematurity
• pregnancy loss
SEXUAL AND REPRODUCTIVE
HEALTH
• unwanted pregnancy
• abortion
• HIV
• other STIs
• gynaecological problems
SUBSTANCE USE
alcohol
other drugs
• tobacco
•
•
NONCOMMUNICABLE
DISEASES
• cardiovascular
disease
• hypertension
SOMATOFORM
• irritable bowel
• chronic pain
• chronic pelvic
pain
DISABILITY
•
homicide
DEATH
• suicide
•
other
There are multiple pathways through which intimate partner violence can lead to adverse health outcomes. This figure highlights three
key mechanisms and pathways that can explain many of these outcomes. Mental health problems and substance use might result
directly from any of the three mechanisms, which might, in turn, increase health risks. However, mental health problems and substance
use are not necessarily a precondition for subsequent health effects, and will not always lie in the pathway to adverse health.
Prevalence and health effects of intimate partner violence and non-partner sexual violence
Section 1: Methodology
This section of the report briefly describes the
high-income countries from the different regions
methods used for calculating the global and
(See Appendix 1 for tables detailing the countries
regional prevalence estimates of intimate partner
for which data are available in each region).
violence and non-partner sexual violence.
Measurement of exposure to
intimate partner violence and nonpartner sexual violence
The global estimate for intimate partner violence
and non-partner sexual violence is based on the
regional weighted prevalence estimates using
Global Burden of Disease (GBD) regions (19), since
these regions are broken into finer categories that
There is growing consensus on how to measure
are more meaningful epidemiologically. Regional
exposures to different forms of interpersonal
estimates for intimate partner violence and non-
violence, with most work focusing on the
partner sexual violence for these regions are
measurement of violence by an intimate partner
included in Tables A2.1 and A2.2 in Appendix 2.
(15, 16). Gold standard methods to estimate the
prevalence of any form of violence are obtained
by asking respondents direct questions about
their experience of specific acts of violence over
a defined period of time, rather than using more
generic questions about whether the respondent
has been “abused” or has experienced “domestic
violence” or “rape” or “sexual abuse”, which
tends to yield less disclosure. Methodological
issues related to the implementation of the survey
procedures – including the selection and levels of
training of interviewers, and ensuring appropriate
support of respondents and interviewers, have
also been shown to influence levels of disclosure
(3, 17, 18).
Definitions of WHO regions
Prevalence estimates of intimate
partner violence
Most population-based research to assess the
prevalence of intimate partner violence focuses on
compiling information on respondents’ exposures
to a range of physical, sexual and emotional/
psychological acts of violence by a current or
former intimate partner, whether cohabiting or not.
Definitions of each of these aspects of violence
are operationalized using behaviourally specific
questions related to each type of violence, ranging
from slaps, pushes and shoves, through to more
severe acts, such as being strangled or burnt, hit
with a fist, threatened with, or having, a weapon
used against you. The Conflict Tactics Scale (CTS)
(20) has been widely used in the United States of
The focus of this review was to obtain both global
America (USA) and elsewhere to document the
and regional evidence on the prevalence of intimate
prevalence of physical partner violence, framing
partner violence and non-partner sexual violence.
violent acts in the context of relationship conflict.
The regional assessments in this report were
The WHO multi-country study on women’s health
based upon the World Health Organization (WHO)
and domestic violence against women (21) and
regions, and included low- and middle-income
the violence against women module of the DHS
countries in the Region of the Americas (Latin
(22) are adapted versions of the CTS that also
America and the Caribbean), the African Region,
ask about a set of behaviourally specific acts that
the Eastern Mediterranean Region, the European
women experience, without framing the questions
Region, the South-East Asia Region, and the
as gradations of relationship conflict, but rather as
Western Pacific Region, as well as a category for
independent acts in a constellation of experiences
9
10
Global and regional estimates of violence against women
encompassing partner violence. These instruments
have been applied in numerous settings and are
considered valid and reliable measures of intimate
partner violence.
Compilation of evidence on the
prevalence of intimate partner
violence
A systematic review of the prevalence of intimate
In general, surveys on intimate partner violence
partner violence was conducted, compiling
ask respondents about their exposure ever (in their
evidence from both peer-reviewed literature and
lifetime), and in the past year, with a few studies
grey literature from first record to 2008; the
also asking about violence in the last month or
peer-reviewed component was then updated to
within a particular relationship. This report focuses
9 January 2011. For this, a search was conducted
on assessing women’s lifetime exposure to physical
of 26 medical and social science databases in all
or sexual violence, or both, by an intimate partner.
languages, yielding results in English, Spanish,
This is defined as the proportion of ever-partnered
French, Portuguese, Russian, Chinese and a few
women who reported having experienced one or
other languages. Controlled vocabulary terms
more acts of physical or sexual violence, or both,
specific to each database were used (e.g. MeSH
by a current or former intimate partner at any point
terms for Medline). Only representative population-
in their lives (See Table 1, footnote a for a definition
based studies with prevalence estimates for
of intimate partner). Current prevalence is defined
intimate partner violence in women of any
as the proportion of ever-partnered women
age above 15 years were included. Any author
reporting that at least one act of physical or sexual
definitions of intimate partner violence were
violence, or both, took place during the 12 months
included. A total of 7350 abstracts were screened.
prior to the interview.
Additional analysis of the WHO multi-country study
It should be noted that intimate partner violence
on women’s health and domestic violence against
also includes emotional abuse (being humiliated,
women (21) (10 countries) was also performed, and
insulted, intimidated or threatened, for example)
additional analyses of the International Violence
and controlling behaviours by a partner, such as
Against Women Surveys (IVAWS, 8 countries)
not being allowed to see friends or family (23,
(25), GENACIS: Gender, alcohol and culture: an
24). This form of abuse also impacts the health of
international study (16 countries) (26) and the DHS
individuals. However, there is currently a lack of
(20 countries) (4, 22) were also conducted. In
agreement on standard measures of emotional/
total, 185 studies from 86 countries representing
psychological partner violence and the threshold
all global regions met our inclusion criteria, and
at which acts that can be considered unkind or
data from 155 studies in 81 countries informed our
insulting cross the line into being emotional abuse.
estimates. Of these, 141 studies were used in the
For this reason, emotional/psychological violence
all ages model, 89 were used in the age-specific
has not been included in this analysis, and, for the
model, and 75 were used in both. Of the 14 studies
purposes of this report, the measures of intimate
used only in the age-specific model, nine had
partner violence solely include act(s) of physical
insufficient data for calculating an all-age estimate
and/or sexual violence.
and five had a broader range of age specific data
but were not included in the all-age estimate.
Prevalence and health effects of intimate partner violence and non-partner sexual violence
Sixty-six studies had prevalence data for a broad
Intimate partner violence against older women is
age band so were included in the all ages model
a form of elder maltreatment, and, as is the case
but not in the age-specific model.
with child maltreatment, the categories of intimate
The study focused on extracting data by age group
on ever, and past-year, experience of physical
and sexual violence for ever-partnered women,
making note of the specific definitions used, as
well as elements of the survey characteristics.
Where a breakdown by the severity of violence was
reported, these data were also compiled. For this,
severe violence was categorized by the severity of
partner violence and elder maltreatment are not
mutually exclusive. Violence against children
and the elderly are important areas of research
that merit further investigation and careful
consideration of the special methodological and
safety concerns inherent in research among these
populations.
or burnt on purpose, threatened with a weapon, or
Compilation of evidence on the
prevalence of non-partner sexual
violence
a woman having had a weapon used against her,
A systematic search was used to compile evidence
as well as any act of sexual violence, would be
on the prevalence of non-partner sexual violence.
considered severe violence.
For this, a systematic search of biomedical
Only studies with primary data from population
databases was carried out (British Medical
surveys were included, and only women aged
Journal, British Nursing Index, Cumulative Index
15 years and older were included. In some settings,
to Nursing and Allied Health Literature [CINAHL],
girls are partnered formally or informally before the
Cochrane Library, Embase, Health Management
age of 15 years, but since most surveys capturing
Information Consortium, Medline, PubMed, Science
data on intimate partner violence, especially
Direct, Wiley-Interscience), as well as social
those from low- and middle-income countries,
sciences databases (International Bibliography
focus on women in the reproductive age group
of Social Sciences, PsychINFO, Web of Science)
(15–49 years), 15 years was set as the lower age
and international databases (ADOLEC, African
limit for data extraction. Intimate partner violence
Healthline, Global Health, Index Medicus for the
experienced by girls aged under 18 years can also
WHO Eastern Mediterranean Region (IMEMR),
be considered child abuse or maltreatment, and
Index Medicus for the South-East Asian Region
we stress the importance of recognizing that these
(IMSEAR) and the Western Pacific Region Index
are not mutually exclusive categories (See Table 1,
Medicus (WPRIM), LILACS, Medcarib, Popline)
footnote b).
for studies published from 1998 to 2010. An
the acts of physical violence, so that any severe
acts experienced, such as being beaten up, choked
Similarly, data on women aged over 49 years
were scarce and tended to be from high-income
countries. However, data were extracted for older
age categories, where these had been collected.
Tables A1.3 and A1.4 in Appendix 1 show the
distribution of studies by age group and for all ages
by region for data on intimate partner violence.
independent search was also conducted of
international surveys on violence against women
or surveys that included questions on exposure
to non-partner sexual violence. Specific data sets
included: IVAWS (25); the WHO multi-country study
on women’s health and domestic violence against
women (21); DHS (4, 22); GENACIS (26); CDC RHS
(5) and crime surveys across the globe. Citations
11
12
Global and regional estimates of violence against women
were also followed up and contact was made with
and overlapping of estimates from studies where
experts, giving special attention to studies from
estimates were provided for multiple single
conflict settings, to identify additional studies.
perpetrators (stranger, acquaintance, family
Studies with primary data on population-based
estimates of non-partner sexual violence were
member), the estimate based on the largest sample
was chosen.
included and non-population-based studies were
Estimates based on any author’s definition of
only considered in regions where population
sexual violence were included. Unlike intimate
data were limited. Only women aged 15 years
partner violence, most studies used a single broad
and older were included, to differentiate violence
question such as “Have you ever been forced to
against women from child sexual abuse and to be
have sex or to perform a sexual act when you
consistent with the estimates of intimate partner
did not want to with someone other than your
violence. We again acknowledge, however, that
partner?”, which is known to underestimate
sexual violence occurring between the ages of
prevalence. To prevent double counting, estimates
15 and 18 years is also considered child sexual
from the same study/author were checked and the
abuse and that these categories are not mutually
most relevant paper/estimates were included.
exclusive.
The majority of the study estimates (87%) were
Data on lifetime and current (past year) exposure to
derived from three large international data sets:
non-partner sexual violence were extracted, but it
the WHO multi-country study on women’s health
was generally found that current exposure to non-
and domestic violence against women (21)
partner sexual violence was reported rarely. The
(10 countries), IVAWS (25) (8 countries) and
way in which perpetrators were defined in studies
GENACIS (26) (16 countries). All three studies
was critical in assessing inclusion. For exposure,
used a single question to capture exposure to
sexual violence by all perpetrators other than
non-partner sexual violence since the age of 15
intimate partners (e.g., strangers, acquaintances,
years. All the available DHSs were reviewed (4) and
friends, family members, colleagues, police,
since only eight of the 48 surveys provided data on
military personnel, etc.) was relevant to the
sexual violence by non-partners, only these eight
analysis. Many studies combined perpetrators
surveys could be included.
(intimate partners and non-partner perpetrators)
in the analysis, and studies where intimate partner
perpetrators could not be separated from nonpartners were excluded in order to avoid double
counting of acts captured in the analysis of intimate
partner violence. For example, many crime surveys
(European Survey of Crime and Safety) (27 ) and
International Crime Victim Survey (28) presented
data on sexual victimization, without differentiating
perpetrators.
Sexual violence during conflict perpetrated by
militia, military personnel or police is an important
aspect of non-partner sexual violence. Only six
population studies were identified that reported
on non-partner sexual violence in conflict-affected
settings. Many other studies report on sexual
violence, as described in a recent review – but
few of them are population-based studies or they
do not separate partner and non-partner sexual
violence (29). In this review, two of the studies in
Some studies only reported on single perpetrators,
conflict settings were part of larger multi-country
such as strangers, while many combined non-
studies: the Philippines was part of the IVAWS (25)
partner perpetrators. To prevent double counting
and Sri Lanka was part of the GENACIS project
Prevalence and health effects of intimate partner violence and non-partner sexual violence
A total of 7231 abstracts/records were identified
Methods to obtain regional and
global prevalence estimates of
intimate partner violence and nonpartner sexual violence
for screening and the main reasons for exclusion
Using estimates from all of these data sources,
(26), while the others (29–34) were studies
dedicated to measuring experiences of violence
during conflict.
were incorrect study design/non-population studies
and studies focused on intimate partner violence
or combining perpetrators. A total of 189 records/
abstracts were identified for full-text screening
and, after assessment, 77 studies covering 56
countries were included, producing 412 estimates
from 347 605 participating women aged 15
years and older. Data were found for five of the
six WHO regions, with no data identified for the
WHO Eastern Mediterranean Region. Table A1.2
in Appendix 1 shows a list of the 56 countries and
territories for which data were available.
separately for both intimate partner violence and
non-partner sexual violence, a random effects
meta-regression (the metareg command version
sbe23_1 using residual maximum likelihood with
a Knapp–Hartung modification to the variance
of the estimated coefficients, Stata 12.1) (35,
36) was fitted to produce adjusted prevalence
estimates for all WHO regions and by age groups
(only for intimate partner violence) (37 ). The
estimates of intimate partner violence were
adjusted for differences in definitions of violence
(physical or sexual or both), time periods of
During data extraction, prevalence estimates
measurement (lifetime versus current), severity
were compiled by age group, and data on key
of violence (whether moderate or severe), and
methodological issues related to the context of
whether a study was national or subnational
the study (such as in a conflict setting), or study
(national models being more generalizable) (see
methods (including the question used to ask
Appendix 3 for model descriptions). The covariates
about sexual violence) were included. In practice,
adjusted for in the model for non-partner sexual
more than half (59.7%) of the estimates were
violence included whether fieldworkers were
derived from dedicated studies on violence against
trained (interviewers specially trained in violence
women, and 83.7% were from the three major
research tend to elicit more reliable responses
multi-country studies (WHO, IVAWS, GENACIS).
from respondents as opposed to those who do
The majority of estimates measured lifetime non-
not receive the specialized training), whether
partner sexual violence (81.8%), combined non-
the study was a national study (and therefore
partner perpetrators of sexual violence (93.7%),
more generalizable to the population of the
and used a broad definition of sexual violence
country as a whole), and whether the respondent
(91.5%).
was given a choice of multiple perpetrators as
opposed to a single perpetrator (multiple response
options yield more accurate disclosure). More
details on the methodology are provided in two
forthcoming papers on the prevalence of intimate
partner violence and non-partner sexual violence
respectively (37, 38).
13
14
Global and regional estimates of violence against women
WHO region was included in the model as a
partner sexual violence, age-specific estimates
dummy variable, producing adjusted regional
were also included if no data for “all ages” were
estimates (See Appendix 1 for countries included
reported for the particular study.
in each of the WHO regions for which data were
available). In a second step of the analysis, using
regional estimates derived from regression models
developed for the Global Burden of Disease regions
(See Appendix 2.1), as described elsewhere (37 ),
the global estimate was calculated by weighting
the GBD regional estimates together, based on the
United Nations statistics for the total population
of women aged 15–49 years for each region in
2010 (39). The GBD regions, as opposed to the
WHO regions, were used to calculate the global
prevalence, because the high-income category of
the WHO regions comprised countries from multiple
geographic regions, which affected the population
weighting for the remaining countries in each of
the WHO regions and resulted in a weighted global
prevalence estimate that differed very slightly (by
less than 1%) from the global prevalence derived
from the GBD regions.
Age-group-specific prevalence rates were
estimated for intimate partner violence, but not for
non-partner sexual violence, owing to the limited
number of studies with prevalence estimates by
age for non-partner sexual violence. Included
age-group-specific estimates were categorized
into the following age groups: 15–19, 20–24,
25–34, 35–44, 45–54, 55–64, 65–74, 75–84
and 85+ years. To obtain the global age group
specific estimates the regional estimates were
weighted together based on the regional female
population size for the year 2010 (37, 38). Regionspecific age-group estimates were produced by
combining the dummy variable for region and
the dummy variable for age group, obtaining all
unique combinations. Global age-group-specific
estimates were finally obtained by weighting the
regional age-group estimates by the total regional
population of women in that age group. It should be
For intimate partner violence, only studies of
noted that the age-specific estimates and the “all
ever-partnered women were included. The
ages” estimate do not correspond to each other or
estimates were then adjusted such that they
to any region since age-specific estimates were
reflected the proportion of the total population of
calculated using studies reporting age-specific
women experiencing intimate partner violence,
results, and results for “all ages” were calculated
by multiplying the estimates by the age and
including only those studies explicitly reporting an
study year and the country-specific proportion
estimate for “all ages”.
of women who had ever had sexual intercourse,
which was assumed to be a proxy for “everpartnered” (personal communication, S Lim,
Associate Professor of Global Health, Institute for
Health Metrics and Evaluation at the University of
Washington, 2013).
For intimate partner violence, only the studies
reporting estimates for “all ages” were included in
the regional prevalence estimates, while for non-
An estimate of the combined proportion of physical
and/or sexual intimate partner violence and nonpartner sexual violence was calculated by using
data from the regional prevalence results presented
in this report for non-partner sexual violence and
for the regional prevalence results of intimate
partner violence among all women. The proportion
Prevalence and health effects of intimate partner violence and non-partner sexual violence
of all women who had experienced physical or
and sexual violence and non-partner sexual
sexual intimate partner violence and/or non-partner
violence. The relative proportion of women who
sexual violence for each region was calculated
had experienced intimate partner violence and
using the following formula:
had also experienced non-partner sexual violence
a*(100–c)+b
where a is the proportion of all women who had
experienced intimate partner violence, from
the prevalence estimates for all women (results
presented in the report for intimate partner
violence are among ever partnered women but
for the combined estimate are for all women); b is
the proportion of women who had experienced
non-partner sexual violence, from the prevalence
estimates; and c is the proportion of women who
had experienced both intimate partner physical
(c) was calculated using regional data from the
original 10 countries (15 sites) participating in the
WHO multi-country study on women’s health and
domestic violence against women (21), in which
questions on both intimate partner violence and
non-partner sexual violence were asked of the
same women. Global estimates were calculated
using population weights for the WHO regions,
resulting in a global prevalence that shows the
proportion of women who had experienced intimate
partner violence or non-partner sexual violence, or
both.
15
16
Global and regional estimates of violence against women
Section 2: Results – lifetime prevalence estimates
Global and regional prevalence
estimates of intimate partner
violence
Table 3 shows the lifetime prevalence of intimate
partner violence by age groups among everpartnered women. What is striking is that the
prevalence of exposure to violence is already
This section presents the global and regional
high among young women aged 15–19 years,
prevalence estimates of intimate partner violence
suggesting that violence commonly starts early
and non-partner sexual violence. This is the first
in women’s relationships. Prevalence then
time that such a comprehensive compilation of all
progressively rises to reach its peak in the age
available global data has been used to obtain global
group of 40–44 years. The reported prevalence
and regional prevalence estimates. Estimates are
among women aged 50 years and older is lower,
based on data extracted from 79 countries and two
although the confidence intervals around these
territories.
estimates are quite large, and a closer examination
The global prevalence of physical and/or sexual
of the data reveals that data for the older age
intimate partner violence among all ever-partnered
groups come primarily from high-income countries
women was 30.0% (95% confidence interval
(see Table A1.3 in Appendix 1). Since most of
[CI] = 27.8% to 32.2%). The prevalence was
the surveys on violence against women or other
highest in the WHO African, Eastern Mediterranean
surveys with a violence module, such as the DHS
and South-East Asia Regions, where approximately
or RHS, are carried out on women aged 15 or 18
37% of ever-partnered women reported having
to 49 years, fewer data points are available for the
experienced physical and/or sexual intimate
over-49 age group. For this reason, it should not
partner violence at some point in their lives
be interpreted that older women have experienced
(see Table 2). Respondents in the Region of the
lower levels of partner violence, but rather that less
Americas reported the next highest prevalence,
is known about patterns of violence among women
with approximately 30% of women reporting
aged 50 years and older, especially in low- and
lifetime exposure. Prevalence was lower in the
middle-income countries.
high-income region (23%) and in the European and
the Western Pacific Regions, where 25% of everpartnered women reported lifetime intimate partner
violence experience (see Figure 2).4
The global lifetime prevalence of intimate partner
violence among ever-partnered women is 30.0%
(95% CI = 27.8% to 32.2%.)
4. More recent studies from the Western Pacific Region using
the WHO study methodology have since been published, but
were not available at the time the data were compiled. They
show very high prevalence rates of physical and/or sexual intimate partner violence between 60% and 68% (40–42).
Prevalence and health effects of intimate partner violence and non-partner sexual violence
Table 2. Lifetime prevalence of physical and/or sexual intimate partner
violence among ever-partnered women by WHO region
WHO region
Prevalence, %
95% CI, %
Low- and middle-income regions:
Africa
36.6
32.7 to 40.5
Americas
29.8
25.8 to 33.9
Eastern Mediterranean
37.0
30.9 to 43.1
Europe
25.4
20.9 to 30.0
South-East Asia
37.7
32.8 to 42.6
Western Pacific
24.6
20.1 to 29.0
23.2
20.2 to 26.2
High income
CI = confidence interval.
Table 3. Lifetime prevalence of intimate partner violence by age group
among ever-partnered women
Age group, years
Prevalence, %
95% CI, %
15–19
29.4
26.8 to 32.1
20–24
31.6
29.2 to 33.9
25–29
32.3
30.0 to 34.6
30–34
31.1
28.9 to 33.4
35–39
36.6
30.0 to 43.2
40–44
37.8
30.7 to 44.9
45–49
29.2
26.9 to 31.5
50–54
25.5
18.6 to 32.4
55–59
15.1
6.1 to 24.1
60–64
19.6
9.6 to 29.5
65–69
22.2
12.8 to 31.6
CI = confidence interval.
17
18
Global and regional estimates of violence against women
Figure 2. Global map showing regional prevalence rates of intimate partner violenceby WHO region* (2010)
* Regional prevalence rates are presented for each WHO region including low- and middle-income countries, with high income
countries analyzed separately. See Appendix 1 for list of countries with data available by region.
Global and regional prevalence
estimates of non-partner sexual
violence
especially as most of the regional estimates have wide
confidence intervals. As well as real differences in the
prevalence of non-partner sexual violence, the figures
are likely to be subject to differing degrees of under-
The adjusted lifetime prevalence of non-partner sexual
violence by region, based on data from 56 countries and
two territories, is presented in Table 4. Globally, 7.2%
(95% CI = 5.3% to 9.1%) of women reported ever having
experienced non-partner sexual violence. There were
variations across the WHO regions. The highest lifetime
prevalence of non-partner sexual violence was reported
in the high-income region (12.6%; 95% CI = 8.9% to
16.2%) and the African Region (11.9%; 95% CI = 8.5%
to 15.3%), while the lowest prevalence was found for the
South-East Asia Region (4.9%; 95% CI = 0.9% to 8.9%).
These differences between regions may arise for many
reasons, and need to be interpreted with caution,
reporting by region. Sexual violence remains highly
stigmatized in all settings, and even when studies take
great care to address the sensitivity of the topic, it is
likely that the levels of disclosure will be influenced
by respondents’ perceptions about the level of stigma
associated with any disclosure, and the perceived
repercussions of others knowing about this violence.
The global lifetime prevalence of non-partner
sexual violence is 7.2% (95% CI = 5.3% to 9.1%).
Age-specific prevalence rates are not included because
of the lack of availability of age-specific data.
Prevalence and health effects of intimate partner violence and non-partner sexual violence
Table 4. Lifetime prevalence of non-partner sexual violence by WHO region
WHO region
Prevalence, %a
95% CI, %
Low- and middle-income regions:
Africa
11.9
8.5 to 15.3
Americas
10.7
7.0 to 14.4
–
Eastern Mediterraneanb
–
Europe
5.2
0.8 to 9.7
South-East Asia
4.9
0.9 to 8.9
Western Pacific
6.8
1.6 to 12.0
12.6
8.9 to 16.2
High income
CI = confidence interval.
a
Results adjusted for interviewer training, whether the study was national and whether response options were broad
enough to allow for different categories of perpetrators or were limited to a single category of perpetrator.
b
No data were found for countries in this region, therefore a prevalence estimate is not provided
The prevalence of non-partner sexual violence
population as well as in conflict-affected settings.
among conflict-affected countries is an important
As compared to intimate partner violence, fewer
aspect of the analysis, and data specific to conflict
studies include questions on non-partner sexual
settings were identified (25, 26, 30–34, 43).
violence, there are more regions and countries
However, these data were not analysed separately
for which no data are available, and it is not
because data were only available from six conflict-
clear whether the questions being used generate
affected countries and there was a high amount
accurate disclosure. While both forms of violence
of variability in the sampling methodology, with
remain stigmatized, which impacts reporting,
several of the studies using population-based
in many settings sexual violence is even more
surveys of the entire country and others sampling
stigmatized, resulting in self-blame and shame,
specifically in conflict-affected regions. The
and disclosure may even put women’s lives at
lowest prevalence was reported from estimates
risk. In addition, the measurement of intimate
from two large multi-country studies (IVAWS and
partner violence is more advanced than that of
GENACIS), while the higher prevalence estimates
non-partner sexual violence, and there is more
were from studies that focused on measuring
agreement among researchers on how to measure
violence in conflict-affected settings. It is often
it.
difficult to conduct population-based studies in
conflict-affected settings, and obtaining a truly
representative sample may be difficult because of
logistical or security issues.
Although we are aware that the data for nonpartner sexual violence were not as robust or
extensive as for intimate partner violence, it is
likely that the differences in prevalence of non-
This review brings to light the lack of data on
partner sexual violence as compared to intimate
non-partner sexual violence in the general
partner violence reflect actual differences. It
appears that intimate partner violence, which
19
20
Global and regional estimates of violence against women
includes sexual violence, is considerably more
prevalent and more common than non-partner
sexual violence, as shown consistently in all
regions.
Combined estimates of the
prevalence of intimate partner
violence and non-partner violence
Globally, 35.6% of women have ever experienced
When considering non-partner sexual violence
either non-partner sexual violence or physical or
in the context of violence against women and
sexual violence by an intimate partner, or both.
interpersonal violence in general, it appears that
sexual violence is normative in settings where
violence is common. As was seen in the WHO
multi-country study on women’s health and
domestic violence against women (21), certain
countries that had higher levels of non-partner
sexual violence (Namibia and the United Republic of
Tanzania), compared to others that had lower levels
While there are many other forms of violence that
women are exposed to, the two forms studied
here together represent a large proportion of
the violence women experience globally. The
global combined estimate demonstrates just how
common physical and sexual violence is in the lives
of many women.
(Ethiopia), tended also to have higher rates of other
Regional estimates show prevalence rates of
forms of violence, such as sexual abuse during
intimate partner violence and non-partner sexual
childhood (a form of non-partner sexual violence)
violence combined ranging from 27.2% to 45.6%
and men fighting with other men.
(see Table 5).
Table 5. Lifetime prevalence of intimate partner violence (physical and/or sexual) or
non-partner sexual violence or both among all women (15 years and older) by WHO region
WHO region
Proportion of women reporting intimate partner
violence and/or non-partner sexual violence, %
Low- and middle-income regions:
Africa
45.6
Americas
36.1
Eastern Mediterranean
36.4
Europe
27.2
South-East Asia
40.2
Western Pacific
27.9a
High income
32.7
a
More recent studies from the Western Pacific Region using the WHO study methodology have since been published,
but were not available at the time the data were compiled. They show very high prevalence rates of physical and/or
sexual intimate partner violence between 60% and 68% (40–42).
Prevalence and health effects of intimate partner violence and non-partner sexual violence
Section 3: Results – the health effects of intimate partner
violence and non-partner sexual violence
New systematic reviews were conducted on
a broad range of health effects of exposure to
intimate partner violence and non-partner sexual
violence. For each of these reviews, extensive
searches of electronic databases were carried
out, including African Healthline, Applied Social
Sciences Index and Abstracts, British Medical
Journal, British Nursing Index, the Cochrane
Library, CINAHL, Embase, Health Management
Information Consortium, IMEMR, IMSEAR,
International Bibliography of Social Sciences,
LILACS, MedCarib, Midwives Information and
Health effects of exposure to
intimate partner violence
This section describes the magnitude of the
association between intimate partner violence and
selected health outcomes: incident HIV infection,
incident sexually transmitted infections (STIs),
induced abortion, low birth weight, premature
birth, growth restriction in utero and/or small
for gestational age, alcohol use, depression
and suicide, injuries, and death from homicide
(Figure 1).
Resource Service, NHS Library for Health Specialist
It is important to note that the selected outcomes
Libraries, Ovid Medline, Popline, PsychINFO,
presented here do not reflect the full range of
PubMed, Science Direct, Web of Science, Wiley
health effects of exposure to intimate partner
InterScience and WPRIM.
violence. For those that were chosen for this
These reviews sought to include all published
and unpublished studies that provided data on
the strength of association between the different
forms of violence considered and each health
outcome. In general, no restriction on language or
year of publication was specified. Cross-sectional,
case-control and cohort studies in any population
were eligible for review. All author definitions
of violence were included, and the measures of
exposures used were recorded, along with other
indicators of the study’s quality, and details of the
factors controlled for in the analyses. In each case,
relevant data were extracted using a standardized
form. Random effects meta-analyses were used
analysis, reasons included that there was at
least some evidence from longitudinal studies,
and sufficient published or raw data available to
conduct a robust analysis in multiple settings,
with at least some of the evidence coming from
low- or middle-income countries; at least one
of the studies included in the meta-analysis
demonstrating a temporal order, with the violence
clearly preceding the health risk; and plausible
pathways of causality and mechanisms by which
intimate partner violence can cause the selected
outcome described in the literature. Results of the
included health effects are summarized in Table 6
near the end of this section.
to generate pooled odds ratios for intimate partner
Other physical, mental and sexual and reproductive
violence where appropriate. For the health effects
health effects have been linked with intimate
of non-partner sexual violence, pooled odds
partner violence, and merit similar attention,
ratios were not generated, as there was too much
despite their exclusion from this report. These
variation in the definitions and measurements
include adolescent pregnancy, unintended
used. In these cases, best estimates from the
pregnancy in general, miscarriage, stillbirth,
literature are presented instead.
intrauterine haemorrhage, nutritional deficiency,
abdominal pain and other gastrointestinal
problems, neurological disorders, chronic pain,
disability, anxiety and post-traumatic stress
21
22
Global and regional estimates of violence against women
disorder (PTSD), as well as noncommunicable
analysis placed the most emphasis on the findings
diseases such as hypertension, cancer and
from cohort studies. Through the search, five
cardiovascular diseases. In addition, there is
cohort studies were found. Four of these explored
evidence linking intimate partner violence with
the relationship between exposure to intimate
negative child health and development outcomes,
partner violence and incident HIV or other STI
but these are not included in this report.
infection. Two estimates looking at HIV infection
and incident partner violence were also obtained.
HIV and other sexually transmitted
infections
It was not possible to pool the findings because
Over the past decade, there has been growing
studies; we therefore propose best estimates
recognition that intimate partner violence is an
important contributor to women’s vulnerability
to HIV and STIs (45–49). The mechanisms
underpinning a woman’s increased vulnerability
to HIV or STIs include direct infection from forced
sexual intercourse, as well as the potential
for increased risk from the general effects of
prolonged exposure to stress (49, 50). Women in
violent relationships, or who live in fear of violence,
may also have limited control over the timing or
circumstances of sexual intercourse, or their ability
to negotiate condom use (51). Partner violence may
also be an important determinant of separation,
which in turn may increase a woman’s risk of HIV
if she acquires a new partner. Furthermore, there
is behavioural evidence that men who use violence
against their female partners are more likely
than non-violent men to have a number of HIV-
different measures were reported in different
based on the available studies. Of the studies of
incident HIV/STI, the three large studies (58–60)
( > 1000 participants) (two on HIV from subSaharan Africa and one on STI from India) found
an increased risk of HIV/STI among those reporting
partner violence. The fourth study (61), among
women attending substance-use treatment clinics
in the USA, used self-reported data on HIV and STI
diagnosis, and found some evidence of a lower
risk of HIV among those reporting intimate partner
violence. The two studies looking at incident
intimate partner violence (61, 62) (after HIV or STI
diagnosis) found inconsistent results. The best
estimates of association between intimate partner
violence and HIV/STIs are odds ratio (OR) = 1.52
(95% CI = 1.03 to 2.23) for HIV (58); adjusted
odds ratio (aOR) = 1.61 (95% CI = 1.24 to 2.08)
for syphilis (63), and OR = 1.81 (95% CI = 0.90 to
risk behaviours, including having multiple sexual
3.63) for chlamydia or gonorrhea (59).
partners (52), frequent alcohol use (53), visiting
The review findings highlight the need for further
sex workers (54), and having an STI (55, 56), all of
research. Larger and more representative cohort
which can increase women’s risk of HIV.
studies from Africa and India show an association
Forty-one studies were identified for inclusion in
between experience of intimate partner violence
the review commissioned for this report (57 ). These
included cohort, case-control and cross-sectional
studies. The strongest evidence comes from cohort
studies that use biological outcome measures, and
allow determination of whether violence precedes
incident HIV/STI infection. For this reason, although
all of the evidence found was extracted, the
and biologically confirmed incident HIV/other STIs.
However, one smaller, lower-quality cohort study
from a population with high competing risks for HIV
infection showed an inverse relationship. Evidence
from a broader range of settings is needed,
to assess the degree to which the association
between exposure to violence and incident HIV is
also found in other HIV epidemic settings.
Prevalence and health effects of intimate partner violence and non-partner sexual violence
Induced abortion
Violent relationships are frequently marked by fear
and controlling behaviours by partners, so it is not
surprising that women in these relationships report
more adverse sexual and reproductive health
outcomes. The higher rates of adverse reproductive
events can be explained by direct consequences of
sexual violence and coercion, as well as by more
indirect pathways affecting contraceptive use, such
as sabotage of birth control, disapproval of birth
abortion, tend to be underreported, particularly
in settings where it is illegal, but the inclusion of
case-control studies involving abortion patients
provided important evidence of association. These
findings emphasize the importance of addressing
intimate partner violence in health settings,
particularly in sexual and reproductive health
services.
Low birth weight and prematurity
control preventing use of contraception, or inability
Low birth weight can result from either preterm
to negotiate condom use for fear of violence (64).
birth or growth restriction in utero, both of which
As a result, women in abusive relationships have
can be directly linked to stress. Living in an abusive
more unintended pregnancies (65–67 ). Of the
and dangerous environment marked by chronic
estimated 80 million unintended pregnancies
stress can therefore be an important risk factor for
each year, at least half are terminated through
maternal health, as well as affecting birth weight.
induced abortion (68) and nearly half of those take
All observational studies (cohort, case-control, and
place in unsafe conditions (69). While unintended
pregnancies carried to term have been associated
with health risk to mothers and infants, illegal and
unsafe abortions place women’s health at even
greater risk.
cross-sectional) that investigated intimate partner
violence and the potential association with low
birth weight/preterm birth/growth restriction in
utero were considered. Only studies for which the
perpetrator was limited to the intimate partner and
Analysis of data from 31 studies provides strong
for which violence was limited to physical and/or
evidence that women with a history of intimate
sexual were eligible for review. Low birth weight
partner violence are more likely to report having
was defined as < 2500 g, preterm birth was
had an induced abortion (pooled OR = 2.16, 95%
defined as gestational age of less than 37 weeks,
CI = 1.88 to 2.49). Similar results were found in
and growth restriction in utero and/or small for
a subanalysis of five studies in which it could be
gestational age was defined as birth weight below
confirmed that intimate partner violence preceded
the tenth percentile.
the abortion (OR = 2.38, 95% CI = 1.93 to 2.84).
A total of 17 studies met the inclusion criteria
The effect of other factors, such as the timing
of violence and legality of abortion were also
explored, and explain some of the heterogeneity in
estimates (70).
(13 low birth weight, 10 preterm birth, 3 growth
restriction in utero). Intimate partner violence
was positively associated with low birth weight
(aOR = 1.16, 95% CI = 1.02 to 1.29), as was
The review confirmed that higher rates of induced
preterm birth (aOR = 1.41, 95% CI = 1.21 to
abortion among women with a history of intimate
1.62), even after adjusting for confounding
partner violence are consistently found in a variety
factors. No statistically significant association
of study designs and among diverse population
was found between intimate partner violence and
groups. Sensitive and stigmatized events, such as
intrauterine growth restriction (aOR = 1.36, 95%
CI = 0.53 to 2.19). Heterogeneity scores were
23
24
Global and regional estimates of violence against women
statistically significant in the analysis of low birth
Overall, longitudinal studies illustrate that the
weight, but they were much lower for growth
relationship between alcohol use and violence
restriction in utero and preterm birth (71).
is bidirectional. There is a positive association
Given the known causal mechanisms of stressrelated responses affecting birth weight and the
consistent positive association found, these results
suggest that intimate partner violence is indeed an
important risk factor for having low-birth-weight
babies.
between women’s experience of intimate partner
violence and subsequent alcohol use, as well as an
association between alcohol use and subsequent
intimate partner violence. Although the causal
relationship between experience of intimate partner
violence and alcohol consumption in women is
far from clear, there is clear evidence that women
Harmful alcohol use
with histories of violence consume more alcohol,
Harmful use of alcohol and violence are
consume alcohol in other harmful ways are more
intertwined. As well as alcohol being an important
facilitator of men’s use of violence, there is also
evidence of an association for women between
violence and frequent alcohol use. The nature of
this association is likely to be complex. Women
may drink alcohol to cope with the sequelae of
abuse, but, conversely, women’s consumption of
alcohol may result in abuse from their partners, for
example, because their partners believe that they
should not drink.
and, conversely, that women who binge drink and
likely to report experiences of violence. It is also
possible that both alcohol use and intimate partner
violence can be attributed to another underlying
issue, such as a mental health disorder or another
substance use, which can increase women’s
vulnerability to violence and to alcohol use. Public
health programming needs to address alcohol use
in prevention and treatment of intimate partner
violence, and experiences of violence need to be
addressed in alcohol misuse programmes.
The review identified a total of 37 studies,
providing 77 estimates of association between
Depression and suicide
physical and/or sexual intimate partner violence
Traumatic stress is thought to be the main
and alcohol use.
mechanism that explains why intimate partner
Six longitudinal studies, with 10 estimates,
violence may cause subsequent depression and
examined whether intimate partner violence was
suicide attempts. Exposures to traumatic events
associated with incident alcohol use. All of these
can lead to stress, fear and isolation, which,
longitudinal estimates showed a positive direction
in turn, may lead to depression and suicidal
of association between intimate partner violence
behaviour (74). Again, the relationship may be
and incident alcohol use, although not all were
bidirectional: other studies suggest that women
statistically significant (72). The best estimate from
with severe mental health difficulties are more
the available literature is from a longitudinal study
likely to experience violent victimization (75, 76).
on women’s health in Australia, in which alcohol
Developmental and early life exposures to violence
abuse was measured subsequent to disclosure of
and other traumas may also play an important role
intimate partner violence. This study reported an
in predicting both violence and depression (77, 78).
OR of 1.82 (95% CI = 1.04 to 3.18) (73).
Seventeen papers were identified, reporting on 16
studies, giving a total of 36 163 participants, and
containing 55 effect estimates (79). For violence
Prevalence and health effects of intimate partner violence and non-partner sexual violence
and incident depression, the pooled OR from
practical measure of interest in understanding the
six studies was 1.97 (95% CI = 1.56 to 2.48).
health effects of intimate partner violence is the
There was some heterogeneity between studies
prevalence of injury directly attributable to partner
(I = 50.4%, P = 0.073), but all estimates but one
violence, not the relative rate of injury among
showed a positive direction of effect. Three studies
women experiencing and not experiencing partner
(80–82) examined violence and subsequent suicide
violence. The few studies for which this relative risk
attempts. All three showed positive relationships;
information was available were analysed, and the
two were statistically significant and one was
relative risk data are presented below. Population-
borderline significant. A pooled OR of 4.54 (95%
based surveys, such as the DHS in countries that
CI = 1.78 to 11.61) was calculated from these three
included a module on intimate partner violence
studies (80–82).
with questions inquiring about physical injuries
5
2
due to violence, complement these sources of data
Non-fatal injuries
Intimate partner violence is associated with
many health consequences, but the most direct
effects are fatal and non-fatal physical injuries.
It is estimated that approximately half of women
in abusive relationships in the USA are physically
injured by their partners, and that most of them
sustain multiple types of injuries (83). The head,
neck and face are the most common locations
of injuries related to partner violence, followed
by musculoskeletal injuries and genital injuries.
Measurement of injuries resulting from intimate
partner violence remains challenging for many
reasons.
Unlike other health effects of violence, measuring
the relative risk of injury among women
experiencing intimate partner violence as
compared to women with no partner violence is
less relevant and generally not feasible. Practically
speaking, studies do not quantify injuries among
women who are not experiencing partner violence,
and therefore relative risks were not presented or
were not calculable in most of the studies. A more
5. In meta-analyses, tests of heterogeneity (e.g. I2) are used
to show how much the individual studies show variability as
opposed to consistency of results across studies. Higher heterogeneity scores that are statistically significant indicate that the
variability is not due to chance alone.
and provide a more direct estimate of injuries due
to violence. These population-based data can be
considered a more reliable and valid data source
for these purposes, since they capture treated
as well as untreated injuries that can be directly
attributable to partner violence (because of the
wording used in the surveys, which asks women
who have experienced intimate partner violence
whether they sustained injuries from the violence).
The self-reported nature of the results, and the
potential recall bias when time has elapsed, can
bias the findings; however, given the limitations of
the different data sources, the population-based
studies provide more direct estimates of better
quality.
Hospital- and clinic-based data were not included
in this analysis, since surveillance data from clinics
or hospitals, when available, vastly underestimate
injuries due to violence for several reasons:
many women, regardless of health systems in
their country, do not seek health care for injuries
25
26
Global and regional estimates of violence against women
caused by partner violence (84),6 and if they do,
systematic review of all published and unpublished
many or most hospitals do not collect perpetrator
studies released between 1 January 1994 and
information. Furthermore, even when asked about
31 December 2011 found 2167 abstracts, of
perpetrators, women presenting with injuries due
which 118 studies that examined the proportion of
to partner violence may be reluctant to disclose the
intimate partner homicides were included. Second,
actual source of the injury, attributing the injury to
a survey was conducted among 169 countries with
some other cause.
official data sources and relevant web pages or
Random effects meta-analysis was conducted to
summarize the data extracted from the 11 papers
and data from the 31 countries with populationbased data (85). The proportion of women with
injuries due to intimate partner violence among
all women who had experienced partner violence
was 41.8% (95% CI = 34.0% to 49.6%; weighting
based on inverse variance). The relative risk of
injuries for women with and without intimate
contact information to gather country- or regionallevel data on intimate partner homicide. Contact
was made via e-mail with the country statistics
offices, ministries of justice, home offices, or police
headquarters, if relevant information could not
be found on home pages. In total, 226 different
studies and statistics were found, capturing 1121
estimates across 65 countries from 1982 to 2011
(89).
partner violence was calculated where data
For the total estimates, the total numbers of
allowed (i.e. three studies (86–88) for which injury
homicides by intimate partners were added by
rates among women without and women with
sex and divided by the total homicides by sex.
partner violence were presented), showing an
Since some estimates are skewed, the findings
OR of 2.92 (95% CI = 2.21 to 3.63). Despite the
are reported in median percentages. Regional
serious limitations in the published data, the results
estimates are given according to WHO regions.
from the population-based studies added strength
to the analysis, by analysing data from women in
the general population. These results, indicating
that among women experiencing intimate partner
violence 42% were injured by their partners,
shows the potentially enormous health burden for
women as a result of injuries from intimate partner
violence.
Across all countries with available data since 1982:
• the median prevalence of intimate partner
homicide was approximately 13%, with as many
as 38% of all murdered women (in contrast
to 6% of all murdered men) being killed by an
intimate partner;
• the median prevalence of intimate partner
homicide among all murdered women was
Fatal injuries (intimate partner homicides)
highest in the South-East Asia Region, with
Two methods were used to obtain estimates of the
approximately 55%, and the high-income
proportion of male and female homicides where
the perpetrator was an intimate partner. First, a
6. Data from the WHO multi-country study on women’s health
and domestic violence against women (21) confirmed this finding, with data from 14 sites in 9 countries. While, on average,
48% of women experiencing physical intimate partner violence
claimed they needed health care for their injuries, only 36%
actually sought health care for them.
region, with approximately 41%, followed by
the African Region (approximately 40%) and the
Region of the Americas (approximately 38%).
The regional differences in intimate partner
homicide may represent real differences in patterns
of homicide and correspond with the cultural
acceptability of violence against women and the
Prevalence and health effects of intimate partner violence and non-partner sexual violence
prevalence of intimate partner violence against
and were therefore not included. The reviews of
women. However, the regional differences may
the health effects associated with non-partner
also be closely correlated with the completeness
sexual violence reveal the poor state of research
and quality of data on homicides among countries
and highlight the need for dedicated longitudinal
and regions, as there is a lack of data on intimate
studies. No single longitudinal study or systematic
partner homicide in low-income settings, especially
review was found for any of the health associations
in Asia and Africa, and a high amount of missing
with non-partner sexual violence. It was also found
data on the victim–offender relationship in Latin
that health outcomes were not well defined and
America.
both the limited number of studies and the huge
The prevalence rates of intimate partner homicide
presented are likely to be underestimations, since
the victim–offender relationship is often not known
or reported. Over- or underestimations might have
also occurred because the study was restricted to
one estimate per country year, which was averaged
if data for more than one year were available. In
addition, the study favored national representative
variations in the definitions used meant it was not
possible to carry out a meta-analysis. The reviews
conducted for mental health outcomes and harmful
use of alcohol associated with non-partner sexual
violence are summarized in the text below and in a
summary table (Table 7) at the end of this section.
Depression and anxiety
information over small-scale studies, which might
Five studies, all based in the USA, were found to
have gone into more depth, for example through
report associations between non-partner sexual
data triangulation, to establish the victim–offender
violence and depression/anxiety disorders.
relationship.
All studies found a positive association, but
Table 6 summarizes the information on the effect
these were not consistently significant, nor did
sizes for selected health outcomes and intimate
they consistently adjust for relevant factors. A
partner violence.
large female veteran study of 137 006 women
by Kimerling et al. (90), using the diagnostic
Health effects of exposure to nonpartner sexual violence
The health effects of non-partner sexual
violence – in particular the mental health effects
(depression, anxiety disorders, including PTSD) are
often referred to in reports and discussions. This
review showed that population-based evidence
on the strength of these associations is extremely
limited. Currently, most evidence comes from
clinical research and observation, rather than
from longitudinal or case-control studies. Where
the associations are measured, reports of sexual
violence by all types of perpetrators (intimate
and non-intimate partners) are often combined
categories of the Diagnostic and statistical manual
of mental disorders, 4th edition (DSM-IV) (91),
reported an adjusted OR of 2.25 (95% CI = 2.10
to 2.40), while a second, military-based study by
Hankin et al. (92), using a shortened version of
the Centre for Epidemiological Studies Depression
scale (CES-D) (93) (11 items), reported an adjusted
OR of 3.16 (95% CI = 2.68 to 3.72). The study by
Kimerling et al. (90) adjusted for race, age, and
knowing own medical/mental health condition,
while the study by Hankin et al. (92) adjusted for
age and educational level. It appears that neither
of the two military studies adjusted for military
trauma.
27
28
Global and regional estimates of violence against women
The 1998 Women’s Survey (94) found a non-
15 to 20 years, enrolled in schools or professional
significant association between non-partner
training programmes (100). All the studies except
sexual violence and a high score of depression
one (101) reported adjustments for variables such
symptoms (OR = 1.25; 95% CI = 0.61 to 2.59),
as age, race, occupation, employment income and
which was measured using a subscale from the
marital status, while the study among workers
CES-D scale. The cut-off for the high score was not
also adjusted for work-related stress (99).
provided. However, the same study also measured
The two military-sample studies did not report
the association with a physician diagnosis of
whether additional adjustments were made for
depression and/or anxiety within the last 5 years,
work context, i.e. adjustments for military-related
and a significant association was reported
trauma.
(OR = 2.59; 95% CI = 1.17 to 5.72). This study
adjusted for age, race, marital status, education
and income. A similar positive association
between depression and anxiety was found in
a study of 1336 female university employees
(95). This study used a modified CES-D scale to
measure depression, and anxiety was measured
using nine items from the Profile of Mood States
scale (96), with adjustments for race, age and
occupation. Finally, a study among 174 female
patients (97 ) attending an internal medicine clinic
and using the Hopkins checklist (98), reported an
association between non-partner sexual violence
and depression, with an adjusted OR of 2.5 (95%
CI = 1.63 to 7.48).
Alcohol use disorders
There were many differences in what was
considered as alcohol use problems in these
studies, with the study by Kimerling et al. (90)
reporting on alcohol use disorder, which was
quantified according to the mental health and
substance abuse clinical classification using the
DSM-IV (88). Hankin et al. (92) measured “alcohol
abuse”, which was quantified using the five-item
TWEAK scale (an acronym for the five questions
used [T – Tolerance, W – Worried, E – Eye opener,
A – Amnesia – black-outs, K – K/Cut down].
Rospenda et al. (99), reporting on the sample
of university workers, measured associations
between non-partner sexual violence and “problem
drinking”, using a combination of the Michigan
Assessment Screening Test for Alcohol and Drugs
scale (102) with one or more instances of drinking
A limited body of research and differing definitions
to intoxication and one or more instances of heavy
made it impossible to conduct a meta-analysis
episodic drinking. Heavy episodic drinking and
of the available results. The literature search
drinking to intoxication was also measured in
resulted in five eligible studies. These were all
the study among adolescent girls (95), and was
cross-sectional studies (six papers) reporting
based on two questions. This study measured
associations between non-partner sexual violence
“drinking alcohol regularly”, but detail on how
and alcohol use disorders, and will be described
this was measured was not provided. Similarly,
briefly here. Three of the studies are from the
the study among workers in Lima (101) presented
USA (90, 92, 95, 99: references (95) and (99) are
measures of association between non-partner
reports on the same study), one from Switzerland
sexual violence with alcohol consumption but no
(100) and one from Lima, Peru (101). Two of the
detail was provided on how alcohol consumption
studies are based on military samples (90, 92),
was measured.
two on samples from workers (95, 99, 101), and
the Swiss study was among adolescent girls, aged
All six papers reported positive associations with
non-partner sexual violence, with five reporting
Prevalence and health effects of intimate partner violence and non-partner sexual violence
Table 6. Summary of effect size estimates for selected health outcomes and intimate partner violence
Disease/injury
resulting from
violence
Definition
Search date
Sexual
health
HIV/AIDS
Infection with HIV, with or
without progression to AIDS
December 2010
17
OR = 1.52b (1.03 to 2.23)
Syphilis infection
Acute and chronic infection
with Treponema pallidum
December 2010
21
aOR = 1.61c (1.24 to
2.08)
Chlamydia or
gonorrhoea
Bacterial infection with
Chlamydia trachomatis,
transmitted vaginally, anally
or perinatally;d Bacterial
infection with Neisseria
gonorrhoea, transmitted
vaginally, anally or perinatally
December 2010
21
OR = 1.81e (0.90 to 3.63)
Reproductive
health
Induced abortion
Episodes of induced abortion
December 2011
31
OR = 2.16f (1.88 to 2.49)
Perinatal
health
Low birth weight
< 2500 g
June 2012
13
aOR = 1.16g (1.02 to
1.29)
Premature birth
Gestational age < 37 weeks
June 2012
10
aOR = 1.41g (1.97 to
2.60)
Small for gestational
age
Birth weight below the 10th
percentile
June 2012
3
aOR = 1.36g (0.53 to
2.19)
Unipolar depressive
disorders
Depressive episodes
February 2013
16
OR = 1.97h (1.56 to 2.48)
Alcohol use
disorders
Alcohol use disorders;
authors’ definitions
January 2011
36
OR = 1.82i (1.04 to 3.18)
Any injury inflicted
by partner
Injuries inflicted by partner
September
2011
11 papers
+ data
from 31
countries
42% of women with
intimate partner violence
were injured by their
partner (34% to 49.6%)j
Mental
health
Injuries
Number
of studies
identified
Effect size
(95% CI)a
Domain
2.92k (2.21 to 3.63),
comparing injuries
among women with and
without intimate partner
violence
Death
Homicide
Death perpetrated by partner
December 2011
226
Suicide
Death perpetrated by self
November 2011
3
a
Effect size refers to the estimate of association and
is based on either a best estimate from the literature
or a pooled estimate from a meta-analysis.
b
Best estimate (58).
c
Best estimate (63).
Excludes ocular trachoma.
Best estimate (59).
f
Pooled estimate (70).
g
Pooled estimate (71).
h
Pooled estimate from 6 studies (79).
d
e
Approximately 13% of
all murders, 38% of all
female murders and 6%
of all male murdersl
OR = 4.54m (1.78 to
11.61)
Best estimate (73).
j Pooled estimate (85).
k Pooled estimate from 3 studies (86–88).
l Pooled estimate (89).
m Pooled estimate (79)
i
29
30
Global and regional estimates of violence against women
significant associations: alcohol disorders OR = 2.33 (95% CI = 2.15 to 2.53) (90); alcohol
consumption OR = 1.92 (95% CI = 1.62 to 2.38) (101); drinking to intoxication OR = 1.72 (95%
CI = 1.26 to 2.36) (95); alcohol abuse OR = 1.89 (95% CI = 1.27 to 2.60) (92); and drinking
alcohol regularly OR = 1.95 (95% CI = 1.5 to 2.5) (100). Despite the limitation of the estimates,
it is clear that non-partner sexual violence is associated with problem alcohol use. In the
absence of a pooled estimate, the estimate of “alcohol disorders” was used, which was based
on the largest sample (n = 134 894) and which was also based on the DSM-IV (91) clinical
classification of mental health disorders and conditions.
Table 7 summarizes the effect size for depression and alcohol use disorders and non-partner
sexual violence against women.
Table 7. Summary of effect size estimates for depression and alcohol use disorders and nonpartner sexual violence
Domain
Disease/injury
resulting from
violence
Definition
Search date
Number
of studies
identified
Effect size
(95% CI)a
Mental health
Unipolar
depressive
disorders
combined with:
Depressive
episodes
May 2012
5
OR = 2.59b
(1.17 to 5.72)
Anxiety disorders
Including PTSD
and obsessive–
compulsive
disorder
May 2012
5
OR = 2.33c
(2.15 to 2.53)
Alcohol use
disorders
May 2012
a Effect size refers to the estimate of association and is based on either a best estimate from the literature.
b Best estimate (94).
c Best estimate (90).
Prevalence and health effects of intimate partner violence and non-partner sexual violence
Section 4: Summary and conclusions
Summary of findings
This comprehensive review of the prevalence and
health effects of two forms of violence against
women (intimate partner violence and non-partner
sexual violence) marks an important milestone,
not only in the field of research in violence against
The findings highlight that intimate partner violence
is a major contributor to women’s mental health
problems, particularly depression and suicidality,
as well as to sexual and reproductive health
problems, including maternal health and neonatal
health problems.
women, but also in the field of public health in
Globally 35.6% have experienced either intimate
general. This report presents the first global and
partner violence and/or non-partner sexual
regional prevalence estimates of physical and
violence. Nearly one third of ever-partnered women
sexual intimate partner violence against women,
(30.0%) have experienced physical and/or sexual
and non-partner sexual violence against women,
violence by an intimate partner, and 7.2% of adult
using evidence from comprehensive systematic
women have experienced sexual violence by a non-
reviews of global population data.
partner. Some women have experienced both.
The findings confirm the fact that intimate partner
Key findings on health outcomes of physical and
violence and non-partner sexual violence are
sexual intimate partner violence include:
widespread and affect women throughout the
• globally, as many as 38% of all murders of
world. Despite this evidence, many still choose
women are reported as being committed by
to view the violent experiences of women as
intimate partners;
disconnected events, taking place in the private
sphere of relationship conflict and beyond the
realm of policy-makers and health-care providers.
Others blame the women themselves for being
• 42% of women who have been physically and/or
sexually abused by a partner have experienced
injuries as a result of that violence;
subjected to violence, rather than the perpetrators.
• women who have experienced partner violence
In the case of non-partner sexual violence, women
have higher rates of several important health
are blamed for deviating from accepted social
problems and risk behaviours; compared to
roles, for being in the wrong place, or for wearing
women who have not experienced partner
the wrong clothes. In the case of partner violence,
violence, they:
women are blamed for talking to another man,
–– have 16% greater odds of having a low-birth-
refusing sexual intercourse, not asking permission
from their partner (e.g., for going out, visiting their
family), or for not conforming to their role as wives/
partners in some other way.
The health sector in particular has been slow to
engage with violence against women. Yet, this
report presents clear evidence that exposure to
weight baby;
–– are more than twice as likely to have an
induced abortion;
–– are more than twice as likely to experience
depression;
• in some regions, they are 1.5 times more likely
violence is an important determinant of poor health
to acquire HIV, and 1.6 times more likely to have
for women. This is in spite of the fact that this
syphilis,7 compared to women who do not suffer
report has only looked at a limited set of health
partner violence.
outcomes.
7. This association was found for sexual intimate partner
violence only.
31
32
Global and regional estimates of violence against women
The review confirms the degree to which women
physical and mental health in the short and long
with violent partners may be injured. However,
term, contributing to the burden of ill health
despite injury often being perceived to be one of
among survivors. Some studies have shown that
the outcomes of intimate partner violence, the
women who have been raped have higher rates
reviews found surprisingly limited data on this
of use of medical care (e.g. visits to the doctor,
issue, with gaps in population data, particularly
hospitalizations) compared to women who have
on the extent and forms of injury that women
not been raped, even years after the event (103).
experience in different settings.
These data also highlight the need to find better
While, across regions, there are consistently
higher rates of intimate partner violence than nonpartner sexual violence, this does not indicate that
non-partner sexual violence should be given less
ways to help the survivors of sexual violence and
prevent more women and girls from suffering these
experiences in the first place.
attention or be seen as less significant to women’s
Limitations of the review
health. We know that sexual violence remains
The review was constrained by the availability
highly stigmatized, and carries heavy social
of data, and, in particular, of data of sufficient
sanctions in many settings. Furthermore, given the
quality to assess the health burden of both
sensitivities of reporting sexual violence, we know
intimate partner violence and sexual violence by
these estimates are likely to underestimate actual
perpetrators other than partners. It also only looked
prevalence. While measures of partner violence
at a selected number of health outcomes, and was
capture a spectrum of acts of physical, sexual and
unable to assess the level of comorbidity; women
psychological8 violence, ranging from less severe to
suffering intimate partner violence, in particular,
the most severe forms of violence, sexual violence,
are likely to be experiencing more than one health
by definition, is among the most severe forms of
outcome at a point in time.
violence.
The estimates of prevalence and health burden
The fact that, in spite of the constraints to
were limited to physical and sexual intimate
reporting, 7.2% of women globally have reported
partner violence and did not include emotional/
non-partner sexual violence provides important
psychological abuse, even though qualitative
evidence of the extent of this problem. This review
research shows this to be an important element
found that women who have experienced non-
of intimate partner violence, which many women
partner sexual violence are 2.3 times more likely
report as being particularly disabling and resulting
to have alcohol use disorders and 2.6 times more
in ill health. There is a need to strengthen
likely to have depression or anxiety than women
methodologies for measuring this type of violence,
who have not experienced non-partner sexual
testing them cross-culturally and developing
violence.
consensus on them.
This is supported by clinical experience, which
The review has highlighted the data gap in relation
shows that sexual violence can profoundly affect
to non-partner sexual violence, and, in particular,
the need for improving the way in which results
8. This review did not include psychological/emotional violence,
as there are fewer data available and much more variation in
how this is measured across studies.
from studies of sexual violence are reported.
This is most evident in the absence of population
Prevalence and health effects of intimate partner violence and non-partner sexual violence
data from conflict settings, in spite of the growing
also did not discuss the compelling literature on
attention to this issue.
the effects of partner violence on child health
This report also only considers measures of
sexual violence among women aged 15 years or
more. If sexual violence in all of its forms – by
all perpetrators (partners and non-partners),
during childhood and adulthood – were measured
and developmental and behavioural outcomes
(106–109).
Implications of the findings
together, the prevalence rates would be much
Research gaps
higher than those found here. Evidence also shows
This work and these findings highlight several
that women who have experienced one form of
research gaps that must be noted in the
violence are more likely to experience another
interpretation of these data and that should inform
episode of violence, which would not be captured
future research.
in an aggregated measure of sexual violence.
While the global and regional prevalence estimates
presented in this report are an important step in
documenting the epidemiology of this public health
problem, more information is needed to understand
and document sexual violence more accurately.
First, the prevalence estimates highlight several
gaps in population-based data. Many countries
have not collected population-based data on either
intimate partner violence or non-partner violence,
and the prevalence rates for these countries are
unknown. This was most evident in the total
This report has sought to quantify the health
lack of data from the Eastern Mediterranean
burden, but the bidirectional relationship with many
Region on non-partner sexual violence, making it
factors makes this difficult, in the absence of high-
impossible to calculate an estimate for this region.
quality longitudinal data where both the exposures
Looking at the regions in more detail (See Table
to violence and the health outcomes are measured
A.2.1), the regions with the least data available
at multiple time points.
on intimate partner violence were Central Sub-
The number of health outcomes that were included
Saharan Africa, East Asia, Caribbean and Central
in this review was limited for methodological, time
Asia. Countries that do have data often base their
and resource reasons. An important omission
estimates on inadequate survey instruments or
from the review was evidence on the relationship
methodologies. The gold standard for valid data on
between exposures to intimate partner violence
violence against women is currently a stand-alone
and noncommunicable diseases. There is
specialized survey, such as the WHO multi-country
research indicating a relationship with chronic
study on women’s health and domestic violence
conditions, including cardiovascular disease
against women (21), with adequate measures
and hypertension (104) and we are beginning to
taken to address the ethical and safety issues
understand better the potential pathways that
that are unique to this type of research. These
explain these relationships (105). However, this
measures include specialized training of female
was not addressed in this review. The review did
interviewers to collect data in a private space,
look at the relationship with harmful use of alcohol,
in a non-judgmental manner, in the absence of
which, together with smoking (also not addressed
male partners; provision of referrals if necessary;
in this review), is associated with cardiovascular
and interviewing only one woman per household,
and other noncommunicable diseases. The review
to prevent knowledge about the survey content
33
34
Global and regional estimates of violence against women
being shared. The training of interviewers is also
policy and programmatic decision-making. So,
critical and when this is done appropriately, women
while two countries might share a border and
are more likely to disclose their experiences of
might have cultural and other similarities, and the
all forms of violence and are more likely to feel
experience of violence against women may be
supported in their disclosure, particularly when
assumed to be the same in the two places, each
adequate safety measures are taken. Other
country will need to collect its own data, in order
surveys, such as DHS also provide some of these
to understand the risk factors related to violence
safety measures when using the violence against
against women in that particular context and to
women module but, in general, violence modules
respond appropriately. Collecting sound data on the
added to other surveys tend to achieve lower
magnitude and nature of the problem has served
disclosure rates, thereby reducing the overall
in many countries as a stimulus to acknowledge
prevalence rates documented.
and name the problem and initiate discussions on
Second, less is known about how to capture
experiences of sexual violence. Questions on
intimate partner violence have received more
policies and strategies to address it. This will also
provide a baseline against which countries can
measure progress.
attention and the measurement of partner
Finally, the data on health effects are
violence is more advanced in terms of which
predominantly based on cross-sectional studies,
questions to ask and how to capture exposure to
although the analyses in this report preferentially
partner violence, particularly physical and, less
used effect estimates from longitudinal research,
so, sexual partner violence. Revisions have been
where these were available. Proving causality
made or are under way in several large violence
without establishing temporality is not possible,
survey instruments (4, 21), which will improve
although other evidence is provided to support
measurement, and can serve as a model for other
a causal hypothesis for these outcomes. For
surveys on violence. It is less clear whether the
example:
current questions used to capture experiences of
non-partner sexual violence adequately capture the
range of these experiences. Not only do the actual
questions on sexual violence need improvement
and further validation, but multiple experiences
and multiple perpetrators over different time
periods are important aspects of sexual violence
• the causal pathways outlined in the conceptual
framework in Figure 1 provide theoretical
grounding in biological and behavioural
mechanisms through which intimate partner
violence can lead to selected health outcomes;
• the review replicates findings in a variety of
that also need to be captured adequately. These
settings, using population-based surveys;
measurement issues are particularly relevant for
• the review establishes temporal relationships
conflict settings, where this review has shown a
for some of the findings, such as some of the
large gap in robust data.
studies in the intimate partner violence and
Third, it is important to note that differences
abortion analysis and the intimate partner
in political and cultural factors mean that
individual countries need their own data, and that
extrapolating one country’s prevalence estimates
to another is not necessarily appropriate for
violence and low birth weight/prematurity
analyses, since pregnancy outcomes were
recorded by researchers at the time of the study
Prevalence and health effects of intimate partner violence and non-partner sexual violence
and reports of partner violence would have
care – without necessarily disclosing violence
preceded these outcomes;
– particularly in sexual and reproductive health
• in some of the analyses, the review establishes
a dose–response association, with more severe
outcomes found among more severely abused
women;
• most importantly, the review finds strong,
statistically significant associations when data
are pooled for each of these outcomes, even
after adjusting for confounding factors.
The review has maximized the use of the available
data, but stronger conclusions could be made if
more longitudinal data were available, if biological
markers were available for some health issues, and
if more studies controlled for relevant confounding
factors. Better study designs would enable greater
understanding of the nature of the health effects of
intimate partner violence and non-partner sexual
violence.
Conclusions
services (e.g. antenatal care, post-abortion care,
family planning), mental health and emergency
services. The new WHO guidelines for the health
sector response to intimate partner violence and
sexual violence (110) emphasize the urgent need
to integrate these issues into undergraduate
curricula for all health-care providers, as well as in
in-service training.
In relation to sexual violence, whether by a partner
or non-partner, access to comprehensive post-rape
care is essential, and must ideally happen within
72 hours. The new WHO guidelines (110) describe
this as including first-line psychological support,
emergency contraception, prophylaxis for HIV,
diagnosis and prophylaxis for other STIs, and shortand long-term mental health support. This should
also include access to collection and analysis of
forensic evidence for those women who choose to
follow a judicial procedure. Similarly, for intimate
partner violence, access to first-line psychological
In light of these data, in which more than one
support, mental health and other support services
in three women (35.6%) globally report having
needs to be developed and strengthened.
experienced physical and/or sexual partner
This health sector response needs to be part of
violence, or sexual violence by a non-partner, the
a multisectoral response, as recently endorsed
evidence is incontrovertible – violence against
in the Agreed Conclusions of the 57th session of
women is a public health problem of epidemic
the Commission on the Status of Women (2). The
proportions. It pervades all corners of the
Commission makes recommendations for and
globe, puts women’s health at risk, limits their
urges governments and other actors, at all levels,
participation in society, and causes great human
to:
suffering.
The findings underpin the need for the health
sector to take intimate partner violence and
sexual violence against women more seriously.
All health-care providers should be trained to
understand the relationship between violence
and women’s ill health and to be able to respond
• strengthen the implementation of legal and
policy frameworks and accountability;
• address structural and underlying causes and
risk factors, in order to prevent violence against
women and girls;
• strengthen multisectoral services, programmes
appropriately. Multiple entry points within the
and responses to violence against women and
health sector exist where women may seek health
girls.
35
36
Global and regional estimates of violence against women
The high prevalence of these forms of violence
rights; eliminating gender inequalities in access to
against women globally, and in all regions, also
formal wage employment and secondary education
highlights the need to go beyond services and
(111, 112); and, at an individual level, addressing
the importance of working simultaneously on
harmful use of alcohol. Growing evidence from
preventing this violence from happening in the
surveys of men asking about perpetration of rape/
first place. The variation in the prevalence of
sexual assault against non-partners, and physical
violence seen within and between communities,
and sexual violence against partners, also points
countries and regions highlights that violence is not
to the need to address social and cultural norms
inevitable, and that it can be prevented.
around masculinity, gender power relationships and
There is growing evidence about the factors that
violence. (113, 114)
explain much of the global variation. This evidence
This report unequivocally demonstrates that
highlights the need to address the economic
violence against women is pervasive globally and
and sociocultural factors that foster a culture of
that it is a major contributing factor to women’s
violence against women. Promising prevention
ill health. In combination, these findings send a
programmes exist, particularly for intimate partner
powerful message that violence against women
violence, and need to be tested and scaled up.
is not a small problem that only occurs in some
Interventions for prevention include: challenging
pockets of society, but rather is a global public
social norms that support male authority and
health problem of epidemic proportions, requiring
control over women and that condone violence
urgent action. As recently endorsed by the
against women; reducing levels of childhood
Commission on the Status of Women (2), it is time
exposure to violence; reforming discriminatory
for the world to take action: a life free of violence
family law; strengthening women’s economic
is a basic human right, one that every woman, man
and child deserves.
Prevalence and health effects of intimate partner violence and non-partner sexual violence
References
1. Report of the Fourth World Conference on
Women. New York, United Nations, 1995 (A/
CONF.177/20/Rev.1) (http://www.un.org/
womenwatch/confer/beijing/reports/, accessed
1 April 2013).
2. The elimination and prevention of all forms
of violence against women and girls: agreed
conclusions. In: Commission on the Status of
Women, Fifty-seventh session, 4–15 March
2013. New York, United Nations, 2013 (http://
www.un.org/womenwatch/daw/csw/57sess.
htm, accessed 1 April 2013).
3. Department of Gender and Women’s Health
Family and Community Health, World Health
Organization. Putting women’s safety first:
ethical and safety recommendations for
research on domestic violence against women.
Geneva, World Health Organization, 2001
(WHO/FCH/GWH/01.1).
4. Measure DHS Demographic and Health
Surveys. DHS questionnaire modules
(English, French) (http://www.measuredhs.
com/publications/publication-dhsqm-dhsquestionnaires-and-manuals.cfm, accessed 1
April 2013).
5. Centers for Disease Control and Prevention.
Reproductive health surveys (http://www.cdc.
gov/reproductivehealth/Global/surveys.htm,
accessed 1 April 2013).
6. Krug EG et al., eds. World report on violence
and health. Geneva, World Health Organization,
2002.
7. Black MC, Breiding MJ. Adverse health
conditions and health risk behaviors
associated with intimate partner violence –
United States, 2005. Morbidity and Mortality
Weekly Report, 2008, 57(5):113–117.
8. Black MC. Intimate partner violence and
adverse health consequences. American
Journal of Lifestyle Medicine, 2011, 5(5):428–
439.
9. Howard LM et al. Domestic violence and
severe psychiatric disorders: prevalence and
interventions. Psychological Medicine, 2010,
40(6):881–893.
10. Miller AH. Neuroendocrine and immune
system interactions in stress and depression.
Psychiatric Clinics of North America, 1998,
21(2):443–463.
11. Altarac M, Strobino D. Abuse during pregnancy
and stress because of abuse during pregnancy
and birthweight. Journal of the American
Medical Women’s Association, 2002,
57(4):208–214.
12. Wadhwa PD, Entinger S, Buss C, Lu MC. The
contribution of maternal stress to preterm
birth: issues and considerations. Clinical
Perinatology, 2011, 39:351–384.
13. Campbell JC. Health consequences of
intimate partner violence. The Lancet, 2002,
359(9314):1331–1336.
14. Ellsberg M et al. Intimate partner violence and
women’s physical and mental health in the
WHO multi-country study on women’s health
and domestic violence: an observational study.
The Lancet, 2008, 371(9619):1165–1172.
15. García-Moreno C et al. Violence against
women. Science, 2005, 310(5752):1282–
1283.
16. Krug EG et al. The world report on
violence and health. The Lancet, 2002,
360(9339):1083–1088.
17. Jansen HAFM et al. Interviewer training in
the WHO multi-country study on women’s
health and domestic violence. Violence Against
Women, 2004, 10(7):831–849.
18. Ellsberg M et al. Researching domestic
violence against women: methodological
and ethical considerations. Studies in Family
Planning, 2001, 32(1):1–16.
37
38
Global and regional estimates of violence against women
19. University of New South Wales, Global Burden
of Disease Mental Disorders and Illicit Drug
Use Expert Group. Regions (http://www.
gbd.unsw.edu.au/gbdweb.nsf/page/regions,
accessed 8 April 2013).
29. Peterman A, Palermo T, Bredenkamp C.
Estimates and determinants of sexual violence
against women in the Democratic Republic
of Congo. American Journal of Public Health,
2011, 101(6):1060–1067.
20. Straus MA et al. The revised conflict tactics
scales (CTS2). Journal of Family Issues, 1996,
17(3):283–316.
30. Johnson K et al. Association of combatant
status and sexual violence with health and
mental health outcomes in post-conflict
Liberia. JAMA, 2008, 300(6):676–690.
21. García-Moreno C et al. WHO multi-country
study on women’s health and domestic
violence against women: initial results on
prevalence, health outcomes and women’s
responses. Geneva, World Health Organization,
2005.
22. Kishor S, Johnson K. Profiling domestic
violence: a multi-country study. Calverton, MD,
MEASURE DHS+, ORC Macro, 2004.
23. Coker AL et al. Physical health consequences
of physical and psychological intimate partner
violence. Archives of Family Medicine, 2000,
9(5):451–457.
24. Jewkes R. Emotional abuse: a neglected
dimension of partner violence. The Lancet,
2010, 376(9744):851–852.
25. Johnson H, Ollus, N, Nevala S. Violence
against women. An international perspective.
New York, Springer, 2008.
26. Hettige S. GENACIS: gender, alcohol and
culture: an international study (http://genacis.
org/, accessed 1 April 2013).
27. van Dijk JJM et al. The burden of crime in the
EU, a comparitive analysis of the European
Survey of Crime and Safety (EU ICS) 2005.
Brussels, Gallup Europe, 2007.
28. Naudé CM, Prinsloo JH, Ladikos A.
Experiences of crime in thirteen African
countries: results from the International Crime
Victim Survey, Turin, UNICRI-UNODC, 2006.
31. Johnson K et al., Association of sexual
violence and human rights violations with
physical and mental health in territories of the
Eastern Democratic Republic of the Congo.
JAMA, 2010, 304(5):553–562.
32. Hynes M et al. A determination of the
prevalence of gender-based violence among
conflict-affected populations in East Timor.
Disasters, 2004, 28(3):294–321.
33. Swiss S et al. Violence against women during
the Liberian civil conflict. JAMA, 1998,
279(8):625–629.
34. Amowitz LL et al. Prevalence of war-related
sexual violence and other human rights abuses
among internally displaced persons in Sierra
Leone. Journal of the American Medical
Association, 2002, 287(4):513–521.
35.StataCorp. Intercooled Stata, Version 12.1.
11.0. Houston: StataCorp, 2012.
36. Knapp G, Hartung J. Improved tests for a
random effects meta-regression with a
single covariate. Statistics in Medicine, 2003,
22:2693–2710.
37. Devries K et al. Global prevalence of intimate
partner violence against women (draft
manuscript; available upon request).
38. Abrahams N et al. Global prevalence of nonpartner sexual violence (draft manuscript;
available upon request).
Prevalence and health effects of intimate partner violence and non-partner sexual violence
39. United Nations. Statistics and indicators on
women and men (http://unstats.un.org/unsd/
demographic/products/indwm/default.htm,
accessed 25 April 2013).
40. Secretariat of the Pacific Community. Kiribati
family health and safety study: a study
on violence against women and children.
South Tarawa, Secretariat of the Pacific
Community, 2010 (http://www.spc.int/hdp/
index.php?option = com_docman&task = cat_
view&gid = 89&Itemid = 44, accessed 8 April
2013).
41. Secretariat of the Pacific Community. Solomon
Islands Family Health and Safety Study:
a study on violence against women and
children. Honiara, Secretariat of the Pacific
Community, 2009 (http://www.spc.int/hdp/
index.php?option = com_docman&task = cat_
view&gid = 39&Itemid = 44, accessed 8 April
2013).
42. Vanuatu Women’s Centre in Partnership
with the Vanuatu National Statistics
Office. The Vanuatu National Survey on
Women’s Lives and Family Relationships.
Vanuatu, Vanuatu Women’s Centre, 2011
(http://www.ausaid.gov.au/Publications/
Pages/3407_3327_9971_6560_2865.aspx,
accessed 8 April 2013).
43. Liberia Institute of Statistics and GeoInformation Services (LISGIS) (Liberia),
Ministry of Health and Social Welfare (Liberia),
National AIDS Control Program (Liberia), and
Macro International Inc. Liberia Demographic
and Health Survey 2007. Monrovia, Liberia
Institute of Statistics and Geo-Information
Services (LISGIS) and Macro International Inc.,
2008 (http://www.measuredhs.com/pubs/pdf/
FR201/FR201.pdf, accessed 10 April 2013).
44. García-Moreno C, Watts C. Violence against
women: its importance for HIV/AIDS. AIDS,
2000, 14(Suppl. 3):S253–S265.
45. Maman S et al. The intersections of HIV and
violence: directions for future research and
interventions. Social Science and Medicine,
2000, 50(4):459–478.
46. Andersson N, Cockcroft A, Shea B. Genderbased violence and HIV: relevance for HIV
prevention in hyperendemic countries of
southern Africa. AIDS, 2008, 22(Suppl.
4):S73–S86.
47. Campbell JC et al. The intersection of intimate
partner violence against women and HIV/AIDS:
a review. International Journal of Injury Control
and Safety Promotion, 2008, 15(4):221–231.
48. Coker AL. Does physical intimate partner
violence affect sexual health? A systematic
review. Trauma Violence and Abuse, 2007,
8(2):149–177.
49. Fernandez-Botran R et al. Correlations among
inflammatory markers in plasma, saliva and
oral mucosal transudate in post-menopausal
women with past intimate partner violence.
Brain, Behavior, and Immunity, 2011,
25(2):314–321.
50. Newton TL, et al. Markers of inflammation in
midlife women with intimate partner violence
histories. Journal of Women’s Health, 2011,
20(12):1871–1880.
51. Wingood GM, DiClemente RJ. The effects of
an abusive primary partner on the condom use
and sexual negotiation practices of AfricanAmerican women [see comments]. American
Journal of Public Health, 1997, 87(6):1016–
1018.
52. Dunkle KL et al. Perpetration of partner
violence and HIV risk behaviour among young
men in the rural Eastern Cape, South Africa.
AIDS, 2006, 20(16):2107–2114.
39
40
Global and regional estimates of violence against women
53. Abrahams N et al. Sexual violence against
intimate partners in Cape Town: prevalence
and risk factors reported by men. Bulletin of
the World Health Organization Bulletin, 2004,
82(5):330–337.
62. Maman S et al. HIV-positive women report
more lifetime partner violence: findings from
a voluntary counseling and testing clinic in
Dar es Salaam, Tanzania. American Journal of
Public Health, 2002, 92(8):1331–1337.
54. Gilbert L et al. Intimate partner violence and
HIV risks: a longitudinal study of men on
methadone. Journal of Urban Health, 2007,
84(5):667–680.
63. Diaz-Olavarrieta C et al. The co-occurrence of
intimate partner violence and syphilis among
pregnant women in Bolvia. Journal of Women’s
Health, 2009 18(12):2077–2086.
55. Raj A et al. Perpetration of intimate partner
violence associated with sexual risk behaviors
among young adult men. American Journal of
Public Health, 2006, 96(10):1873–1878.
64. Moore AM, Frohwirth L, Miller E. Male
reproductive control of women who have
experienced intimate partner violence in the
United States. Social Science and Medicine,
2010, 70(11):1737–1744.
56. Santana MC et al. Masculine gender roles
associated with increased sexual risk and
intimate partner violence perpetration among
young adult men. Journal of Urban Health,
2006, 83(4):575–585.
57. Devries K et al. Is intimate partner violence a
risk factor for HIV and STI infection in women?
A systematic review and meta-analysis (draft
manuscript; available upon request).
58. Jewkes RK et al. Intimate partner violence,
relationship power inequity, and incidence
of HIV infection in young women in South
Africa: a cohort study. The Lancet, 2010,
376(9734):41–48.
59. Weiss HA et al. Spousal sexual violence
and poverty are risk factors for sexually
transmitted infections in women: a longitudinal
study of women in Goa, India. Sexually
Transmitted Infections, 2008, 84(2):133–139.
60. Zablotska IB et al. Alcohol use, intimate
partner violence, sexual coercion and HIV
among women aged 15–24 in Rakai, Uganda.
AIDS and Behavior, 2009, 13(2):225–233.
61. El-Bassel N et al. HIV and intimate partner
violence among methadone-maintained
women in New York City. Social Science and
Medicine, 2005, 61(1):171–183.
65. Goodwin MM et al. Pregnancy intendedness
and physical abuse around the time of
pregnancy: findings from the pregnancy risk
assessment monitoring system, 1996–1997.
Maternal and Child Health Journal, 2000,
4(2):85–92.
66. Pallitto CC, Campbell JC, O’Campo P. Is
intimate partner violence associated with
unintended pregnancy? A review of the
literature. Trauma, Violence, and Abuse, 2005,
6(3):217–235.
67. Silverman JG et al. Intimate partner violence
and unwanted pregnancy, miscarriage,
induced abortion, and stillbirth among a
national sample of Bangladeshi women. BJOG:
An International Journal of Obstetrics and
Gynaecology, 2007, 114(10):1246–1252.
68. Singh S. Abortion worldwide: a decade of
uneven progress. New York, Guttmacher
Institute, 2009.
69. Sedgh G et al. Induced abortion: incidence
and trends worldwide from 1995 to 2008. The
Lancet 2012, 379 (9816):625–632.
70. Pallitto C et al. Intimate partner violence and
abortion: results of a meta-analysis (draft
manuscript; available upon request).
Prevalence and health effects of intimate partner violence and non-partner sexual violence
71. Hill A, Pallitto C, Garcia-Moreno C. Intimate
partner violence during pregnancy as a risk
factor for low birth weight, preterm birth, and
intrauterine growth restriction: a systematic
review and meta-analysis (draft manuscript;
available upon request).
72. Devries K et al. Intimate partner violence
victimization and alcohol consumption in
women: a systematic review and meta-analysis
(draft manuscript; available upon request).
73. Vos T et al. Measuring the impact of intimate
partner violence on the health of women in
Victoria, Australia. Bulletin of the World Health
Organization, 2006, 84:739–744.
74. Hyde JS, Mezulis AH, Abramson LY. The ABCs
of depression: integrating affective, biological,
and cognitive models to explain the emergence
of the gender difference in depression.
Psychological Review, 2008, 115(2):291–313.
75. Khalifeh H, Dean K. Gender and violence
against people with severe mental illness.
International Review of Psychiatry, 2010,
22(5):535–546.
76. McPherson M, Delva J, Cranford JA. A
longitudinal investigation of intimate partner
violence among mothers with mental illness.
Psychiatric Services, 2007, 58(5):675–680.
77. Bifulco A et al. Adult attachment style as
mediator between childhood neglect/abuse
and adult depression and anxiety. Social
Psychiatry and Psychiatric Epidemiology, 2006,
41(10):796–805.
78. Doumas DM et al. Adult attachment as a
risk factor for intimate partner violence: the
“mispairing” of partners’ attachment styles.
Journal of Interpersonal Violence, 2008, 23
(5):616–634.
79. Devries K et al. Intimate partner violence
and incident depressive symptoms and
suicide attempts: a systematic review of
longitudinal studies. PLoS Medicine, 2013,
10(5):e1001439.
80. Ackard DM, Eisenberg ME, Neumark-Sztainer
D. Long-term impact of adolescent dating
violence on the behavioral and psychological
health of male and female youth. Journal of
Pediatrics, 2007, 151(5):476–481.
81. Chowdhary N, Patel V. The effect of spousal
violence on women’s health: findings from the
Stree Arogya Shodh in Goa, India. Journal of
Postgraduate Medicine, 2008, 54(4):306–312.
82. Roberts TA, Klein JD, Fisher S. Longitudinal
effect of intimate partner abuse on high-risk
behavior among adolescents. Archives of
Pediatrics and Adolescent Medicine, 2003,
157:875–881.
83. Sheridan DJ, Nash KR. Acute injury patterns
of intimate partner violence victims. Trauma,
Violence, and Abuse, 2007, 8(3):281–289.
84. Tjaden P, Thoennes N. Extent, nature, and
consequences of intimate partner violence:
findings from the National Violence against
Women Survey. Washington DC, National
Institute of Justice, 2000.
85. Pallitto C, Petzold M, Garcia-Moreno C.
Intimate partner violence and physical
injuries: synthesis of the global evidence (draft
manuscript; available upon request).
86. Hegarty K et al. Physical and social predictors
of partner abuse in women attending
general practice: a cross-sectional study.
British Journal of General Practice, 2008,
58(552):484–487.
87. McCauley J et al. The battering syndome
– prevalence and clinical characteristics of
domestic violence in primary-care internal
medicine practices. Annals of Internal
Medicine, 1995, 123(10), 737–746.
88. Rachana C et al. Prevalence and complications
of physical violence during pregnancy.
European Journal of Obstetrics, Gynecology,
and Reproductive Biology, 2002, 103(1):26–
29.
41
42
Global and regional estimates of violence against women
89. Stöckl H et al. The global prevalence of
intimate partner homicide The Lancet.
(forthcoming).
90. Kimerling R et al. The Veterans Health
Administration and military sexual trauma.
American Journal of Public Health, 2007,
97(12)2160–2166.
91. Diagnostic and statistical manual of mental
disorders, 4th ed. Arlington, VA, American
Psychiatric Association, 1994.
92. Hankin CS et al. Prevalence of depressive
and alcohol abuse symptoms among women
VA outpatients who report experiencing
sexual assault while in the military. Journal of
Traumatic Stress, 1999, 12(4):601–612.
93. Kohout FJ et al. Two shorter forms of the
CES-D Depression Symptoms Index. Journal
of Aging and Health, 1993,. 5(2):179–193.
94. Plichta SB, Falik M. Prevalence of violence and
its implications for women’s health. Women’s
Health Issues, 2001, 11(3):244–258.
95. Richman JA et al. Sexual harassment
and generalized workplace abuse among
university employees: prevalence and mental
health correlates. American Journal of Public
Health, 1999, 89(3):358–363.
96. McNair D, Lorr M, Droppleman L. Manual
for the Profile of Mood States (POMS). San
Diego, CA, Educational and Industrial testing
Services, 1971.
97. Nicolaidis C et al. Violence, mental health, and
physical symptoms in an academic internal
medicine practice. Journal of General Internal
Medicine, 2004, 19:819–827.
98. Derogatis LR, Lazarus L. SCL-90-R, Brief
Symptom Inventory, and matching clinical
rating scales. The use of psychological
testing for treatment planning and outcome
assessment. Hillsdale, NJ, Lawrence Erlbaum
Associates, 1994.
99. Rospenda KM et al. Chronicity of sexual
harassment and generalized work-place
abuse: effects on drinking outcomes.
Addiction, 2000, 95(12):1805–1820.
100.Tschumper A et al. Sexual victimization in
adolescent girls (age 15–20 years) enrolled
in post-mandatory schools or professional
training programmes in Switzerland. Acta
Paediatrica, 1998, 87:212–217.
101.Musayón Oblitas FY, Caufield C. Workplace
violence and drug use in women workers in a
Peruvian Barrio. International Nursing Review,
2007, 54(4):339–345.
102.Selzer ML. The Michigan Alcoholism
Screening Test: the quest for a new diagnostic
instrument. American Journal of Psychiatry,
1971, 127:1653–1658.
103.Golding JM et al. Sexual assault history and
use of health and mental health services.
American Journal of Community Psychology,
1988, 16(5):625–644.
104.Coker AL et al. Physical and mental health
effects of intimate partner violence for men
and women. American Journal of Preventive
Medicine, 24(4):260–268.
105.Kendall-Tackett KA, Inflammation,
cardiovascular disease, and metabolic
syndrome as sequelae of violence against
women – the role of depression, hostility and
sleep disturbance. Trauma, Violence, and
Abuse, 2007, 8(2):117–126.
106.Jejeebhoy SJ. Associations between wifebeating and fetal and infant death: impressions
from a survey in rural India. Studies in Family
Planning, 1998, 29(3):300–308.
107.Ziaei S, Naved RT, Ekström EC. Women’s
exposure to intimate partner violence and
child malnutrition: findings from demographic
and health surveys in Bangladesh. Maternal
and Child Nutrition, 2012, Aug 20 doi:
10.1111/j.1740-8709.2012.00432.x.
Prevalence and health effects of intimate partner violence and non-partner sexual violence
108.Asling-Monemi K, Naved RT, Persson LA.
Violence against women and increases in the
risk of diarrheal disease and respiratory tract
infections in infancy: a prospective cohort
study in Bangladesh. Archives of Pediatrics and
Adolescent Medicine, 2009, 163(10):931–936.
112.Heise L. What works to prevent partner
violence? An evidence overview. London:
Crown Copyright, 2011 (https://www.gov.uk/
government/news/dfid-research-what-worksto-prevent-violence-against-women-by-theirpartners, accessed 1 April 2013).
109.Asling-Monemi K, Naved RT, Persson LA.
Violence against women and the risk of fetal
and early childhood growth impairment: a
cohort study in rural Bangladesh. Archives of
Disease in Childhood, 2009, 94(10):775–779.
113. Jewkes R, Nduna M, Jama Shai N, Dunkle K.
Prospective study of rape perpetration by young
South African men: incidence & risk factors.
PLoS One. 2012;7(5):e38210.
110.World Health Organization. Responding to
intimate partner violence and sexual violence
against women: WHO clinical and policy
guidelines. Geneva, World Health Organization,
2013.
111.World Health Organization. Preventing
intimate partner violence and sexual violence
against women. Taking action and generating
evidence. Geneva, World Health Organization,
2010.
114. Naved R T, Huque H, et al. (2011). Men’s
attitudes and practices regarding gender
and violence against women in Bangladesh.
Preliminary findings. Dhaka, ICDDR,B.
115.The World Bank. Country and lending groups
(http://data.worldbank.org/about/countryclassifications/country-and-lending-groups,
accessed 10 April 2013).
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Global and regional estimates of violence against women
Appendix 1: Countries included by WHO region and
age group
Table A1.1. Countries included in intimate partner violence prevalence estimates by WHO region
WHO region
Countries
Low- and middle-income regions:
Africa
Botswana, Cameroon, Democratic Republic of the Congo, Ethiopia,
Kenya, Lesotho, Liberia, Malawi, Mozambique, Namibia, Rwanda,
South Africa, Swaziland, Uganda, United Republic of Tanzania,
Zambia, Zimbabwe
Americas
Brazil, Chile, Colombia, Costa Rica, Dominican Republic, Ecuador,
El Salvador, Haiti, Honduras, Jamaica, Mexico, Nicaragua,
Paraguay, Peru, Plurinational State of Bolivia
Eastern Mediterranean
Egypt, Iran, Iraq, Jordan, Palestinea
Europe
Albania, Azerbaijan, Georgia, Lithuania, Republic of Moldova,
Romania, Russian Federation, Serbia, Turkey, Ukraine
South-East Asia
Bangladesh, Timor-Leste (East Timor), India, Myanmar, Sri Lanka,
Thailand
Western Pacific
Cambodia, China, Philippines, Samoa, Viet Nam
High incomeb
Australia, Canada, Croatia, Czech Republic, Denmark, Finland,
France, Germany, Hong Kong,a Iceland, Ireland, Israel, Japan,
Netherlands, New Zealand, Norway, Poland, South Korea, Spain,
Sweden, Switzerland, United Kingdom of Great Britain and
Northern Ireland, United States of America
a
Data from this territory (not a WHO Member State) were included in the regional estimates.
b
High-income countries are classified by the World Bank based on the gross national income per capita calculated using
the World Bank Atlas method (115 ).
Prevalence and health effects of intimate partner violence and non-partner sexual violence
Table A1.2. Countries included in non-partner sexual violence prevalence estimates by WHO region
WHO region
Countries
Low- and middle-income regions:
Africa
Burkina Faso, Democratic Republic of the Congo, Ethiopia, Ghana,
Kenya, Liberia, Malawi, Mozambique, Namibia, Nigeria, Sierra Leone,
South Africa, Uganda, United Republic of Tanzania, Zambia, Zimbabwe
Americas
Argentina, Belize, Brazil, Costa Rica, Jamaica, Nicaragua, Peru,
Uruguay
Eastern Mediterranean
Europe
Azerbaijan, Kazakhstan, Kosovo, Lithuania, Serbia, Turkey, Ukraine
South-East Asia
Bangladesh, Timor-Leste (East Timor), India, Maldives, Sri Lanka,
Thailand
Western Pacific
Kiribati, Philippines, Samoa
High incomea
Australia, Canada, Czech Republic, Denmark, Finland, Germany, Hong
Kong,b Isle of Man,b Japan, New Zealand, Poland, Spain, Sweden,
Switzerland, United Kingdom of Great Britain and Northern Ireland,
United States of America
a
High-income countries are classified by the World Bank based on the gross national income per capita calculated using the
World Bank Atlas method (115 ).
b
Data from this territory (not a WHO Member State) were included in the regional estimates.
45
46
Global and regional estimates of violence against women
Table A1.3. Number of estimates included in analysis of intimate partner violence by WHO
region and age group
Low and middle-income regions
Age
group,
years
Africa
Americas
Eastern
Mediterranean
Europe
Western
Pacific
SouthEast
Asia
High
income
Total
15–19
44
60
9
29
12
16
28
198
20–24
44
59
7
15
20
16
38
199
25–29
42
59
8
29
18
16
34
206
30–34
44
60
9
31
20
16
36
216
35–39
5
18
2
8
11
1
28
73
40–44
2
13
2
6
6
1
4
34
45–49
42
59
7
10
26
16
31
191
50–54
0
4
1
0
6
0
2
13
55–59
0
4
0
0
0
0
3
13
60–64
2
0
0
0
0
0
5
7
65–69
3
3
1
0
3
0
23
33
Table A1.4. Number of estimates included in analysis of intimate partner violence by region for
all ages combined
Low and middle-income regions
Age
group
All ages
combined
Africa
Americas
Eastern
Mediterranean
Europe
Western
Pacific
SouthEast
Asia
High
income
71
72
18
50
33
34
114
Total
392
Prevalence and health effects of intimate partner violence and non-partner sexual violence
Appendix 2: Prevalence estimates of violence
against women by Global Burden of Disease regions
Intimate partner violence
When the prevalence data are grouped by the 21 regions used in the 2010 Global Burden of Disease (GBD)
study, a more nuanced picture appears. The highest prevalence is found in central sub-Saharan Africa,
where a prevalence of 65.6% of ever-partnered women have experienced intimate partner violence. All
regions of sub-Saharan Africa are above the global average of 26.4%. The lowest prevalence is in East Asia,
with 16.3% of ever-partnered women reporting intimate partner violence. The only other regions below the
global average are high-income Western Europe (19.3%), North America (21.3%), Central Asia (22.9%) and
Southern Latin America (23.7%). The remaining countries have a prevalence of 26% or above. It is important
to note that even in the case of the below-average regions, between one quarter and one fifth of everpartnered women have still experienced partner violence.
Table A.2.1. Prevalence of intimate partner violence by GBD region
Region
Prevalence (95% confidence interval), %
Asia Pacific, High Income
28.45 (20.6 to 36.3)
Asia, Central
22.89 (15.8 to 30.0)
Asia, East
16.30 (8.9 to 23.7)
Asia, South
41.73 (36.3 to 47.2)
Asia, South-East
27.99 (23.7 to 32.2)
Australasia
28.29 (22.7 to 33.9)
Caribbean
27.09 (20.8 to 33.3)
Europe, Central
27.85 (22.7 to 33.0)
Europe, Eastern
26.13 (20.6 to 31.6)
Europe, Western
19.30 (15.9 to 22.7)
Latin America, Andean
40.63 (34.8 to 46.5)
Latin America, Central
29.51 (24.6 to 34.4)
Latin America, Southern
23.68 (12.8 to 34.5)
Latin America, Tropical
27.43 (20.7 to 34.2)
North Africa/Middle East
35.38 (30.4 to 40.3)
North America, High Income
21.32 (16.2 to 26.4)
Oceania
35.27 (23.8 to 46.7)
Sub-Saharan Africa, Central
65.64 (53.6 to 77.7)
Sub-Saharan Africa, East
38.83 (34.6 to 43.1)
Sub-Saharan Africa, Southern
29.67 (24.3 to 35.1)
Sub-Saharan Africa, West
41.75 (32.9 to 50.6)
47
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Global and regional estimates of violence against women
Non-partner sexual violence
This section presents additional data on the prevalence estimates of non-partner sexual violence, grouped
by the 21 regions from the GBD 2010 study. There were variations across the regions, with the prevalence
ranging between 3.3% and 21.0%. The highest prevalence was reported in the sub-Saharan Africa, Central
region (21%) followed by the sub-Saharan Africa Southern (17.4%) region. The large confidence interval
in the sub-Saharan Africa, Central region is most likely due to this being based on a single estimate. The
lowest estimate was reported in the Asia South region (3.3 %), followed by the North Africa/Middle East
region (4.5%).
Table A.2.2. Prevalence of non-partner sexual violence by GBD region
Region
Asia Pacific, High Income
Asia, Central
Asia, East
Asia, South
Asia, South-East
Prevalence (95% confidence interval), %
12.20 (4.21 to 20.19)
6.45 (0 to 13.0)
5.87 (0.15 to 11.59)
3.35 (0 to 8.37)
5.28 (0.94 to 9.61)
Australasia
16.46 (11.52 to 21.41)
Caribbean
10.32 (3.71 to 16.92)
Europe, Central
10.76 (6.14 to 15.38)
Europe, Eastern
6.97 (0 to 14.13)
Europe, Western
11.50 (7.24 to 15.76)
Latin America, Andean
15.33 (10.12 to 20.54)
Latin America, Central
11.88 (7.31 to 16.45)
Latin America, Southern
5.86 (0.31 to 11.42)
Latin America, Tropical
7.68 (2.68 to 12.69)
North Africa/Middle East
4.53 (0 to 12.74)
North America, High Income
13.01 (9.02 to 16.99)
Oceania
14.86 (7.48 to 22.24)
Sub-Saharan Africa, Central
21.05 (4.59 to 37.51)
Sub-Saharan Africa, East
11.46 (7.31 to 15.60)
Sub-Saharan Africa, Southern
Sub-Saharan Africa, West
17.41 (11.48 to 23.33)
9.15 (4.90 to 13.41)
Prevalence and health effects of intimate partner violence and non-partner sexual violence
Appendix 3: Regression models for calculating
regional estimates of intimate partner violence
Regression function to estimate regional levels of intimate partner violence
Intercept is omitted in the model:
Prevalencei = β1*subnational + β2*physvio + β3*sexvio + β4*pastyr + β5*severity +
β6*notviostudy + β7*nointrain + β8*pstatus + β9*region1 +… + β15*region7 + μi
where μi is the residual for the i:th study estimate, and the dummy variables are coded as:
• subnational = 0 if national, 1 if subnational;
• physvio = 0 if physical and/or sexual intimate partner violence, 1 if physical violence only;
• sexvio = 0 if physical and/or sexual intimate partner violence, 1 if sexual violence only;
• pastyr = 0 if lifetime exposure to intimate partner violence, 1 if past-year violence only;
• severity = 0 if any form of intimate partner violence, 1 if severe violence only;
• notviostudy = 0 if study designed to measure violence, 1 if study not indented to measure violence;
• nointrain = 0 if interviewers trained, 1 if not trained;
• pstatus = 0 if ever-partnered women included, 1 if only currently partnered women included;
• region1 to region7 are coded as 1 if study from corresponding region, 0 otherwise.
Regression function to estimate age-group-specific regional levels of
intimate partner violence
Intercept is omitted in the model:
Prevalencei = β1*subnational + β2*physvio + β3*sexvio + β4*pastyr + β5*severity +
β6*notviostudy + β7*nointrain + β8*pstatus + βjk *regioni *agegroupk + μi
where region j *agegroupk denotes all main effects and interactions for all the combinations of regions and
age groups, μi is the residual for the i:th study estimate, and the dummy variables are coded above.
49
50
Global and regional estimates of violence against women
Regression function to estimate regional levels for non-partner sexual violence
Intercept is omitted in the model:
Prevalencei = β1*subnational + β2*nointrain + β3*allnonpartners + β4*region1 + ... + β11*region7 + μi
where μi is the residual for the i:th study estimate, and the dummy variables are coded as:
• subnational = 0 if national, 1 if subnational;
• nointrain = 0 if interviewers trained, 1 if not trained;
• allnonpartners = 0 if not all nonpartners included, 1 if all nonpartners included;
• region1 to region7 are coded as 1 if study from corresponding region, 0 otherwise.